SR 19-28 Dated 06/19

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION – BUREAU OF FAMILY ASSISTANCE (BFA)

SUMMARY

This SR releases additional types of healthcare providers authorized to complete and sign FANF forms related to exemption and incapacity (BFA Forms 720, 752, and 752HH).

BFA Form 752A, Authorization for Release of Protected Health Information for FANF Financial Assistance, which references BFA Forms 752 and 752HH, has been revised accordingly.

Instructions for all forms were revised accordingly. Nepali and Spanish translations of BFA Forms 720 and 752A were revised accordingly.

BACKGROUND

BFA is expanding the types of providers that may verify incapacity to reflect changes to how healthcare is delivered. Additionally, it is not within BFA’s area of expertise to provide guidance on which types of providers may complete these FANF incapacity forms for which types of health conditions. For example, BFA is no longer noting the caveat that CNMs may only complete these forms for pregnancy-related conditions, because this is a presumed restriction; the licensing board for each of the provider types regulates the scope of practice within its profession.

POLICY

BFA Forms 720, 752, and 752HH (FANF forms related to incapacity and exemption) were revised to incorporate additional healthcare provider types authorized to complete and sign the forms.

Forms 720, 752, and 752HH may be completed/signed by nine types of currently licensed healthcare providers:

• Physicians;

• PAs;

• APRNs (CNMs are a type of APRN; CNMs are no longer listed separately);

• Alcohol and Drug Counselors (Master LADCs only);

• Psychologists (board certified);

• Pastoral Psychotherapists;

• Independent Clinical Social Workers;

• Clinical Mental Health Counselors; and

• Marriage and Family Therapists.

BFA Form 752A, Authorization for Release of Protected Health Information for FANF Financial Assistance, which references BFA Forms 752 and 752HH, has been revised accordingly.

Instructions for all forms were revised accordingly. Nepali and Spanish translations of BFA Forms 720 and 752A were revised accordingly.

NEW HEIGHTS & NH EASY SYSTEMS PROCEDURES AND IMPLEMENTATION

No change to New HEIGHTS is needed for the addition of provider types. However, please note that within the next few months, New HEIGHTS will replace all use of “Division of Adult Learning and Rehabilitation (DALR)” with “Medical Exemption Unit (MEU)”, to align with this name change that dates back to 2010. DALR occurs in a variety of places, including but not limited to:

• Left-hand column of the main New HEIGHTS screen (“DALR/Sanctions”);

• The “DALR/Sanctions” section uses DALR frequently, including in headings and pop-up windows;

• The “Work Programs” section uses DALR within the “Individual Demographics” window; and

• The “Application Entry” section uses DALR within the “Disability” window.

DESCRIPTION OF REVISIONS MADE TO FORMS

BFA Form 720, Determination of Incapacity for FANF Financial Assistance, was revised to:

• List the additional types of healthcare providers now authorized to complete and sign the form;

• List health information that has additional privacy protections, which individuals must initial to authorize its release;

• Improve clarity, including changing the title of the form;

• Reduce the reading level on the client’s portion of the form (the front side; the back is for healthcare providers); and

• Enable a healthcare provider to indicate if a parent in a two-parent family is unable to supervise his or child(ren) due to the disability noted on the form, which may enable DHHS to provide childcare assistance.

BFA Form 752, Healthcare Provider Statement of Abilities for FANF Financial Assistance, was revised to:

• List the additional types of healthcare providers now authorized to complete and sign the form;

• Improve clarity, including changing the title of the form;

• Reduce and streamline the information requested from the healthcare provider.

BFA Form 752HH, Healthcare Provider Statement of Necessary Care for a FANF Household Member, was revised to:

• List the additional types of healthcare providers now authorized to complete and sign the form;

• Describe who qualifies as a FANF household member;

• Improve clarity, including changing the title of the form;

• Reduce and streamline the information requested from the healthcare provider.

BFA Form 752A, Authorization for Release of Protected Health Information for FANF Financial Assistance, was revised to:

• Update the titles of BFA Forms 752 and 752HH;

• List health information that has additional privacy protections, which individuals must initial to authorize its release;

• Improve clarity, including changing the title of the form;

• Print on office paper instead of NCR paper (the no-carbon required paper that allows for transfer of written information onto the attached yellow sheet of paper);

• Clarify that this form, signed by the individual, is for his or her healthcare provider and does not need to be returned to the MEU; and

• Reduce the reading level.

Instructions for each form were revised accordingly.

Nepali and Spanish translations of BFA Forms 720 and 752A were revised accordingly. These translations can be ordered from the BFA Policy Unit on an as needed basis, retrieved from the Forms subfolder of the BFA folder on the N drive, or printed from http://www.dhhs.nh.gov/dfa/apply.htm.

District Offices will be provided with an advance supply of BFA Forms 720, 752A, 752, and 752HH at the end of May. The Spanish and Nepali translations of BFA Forms 720 and 752A can be ordered from the BFA Policy Unit on an as needed basis, or retrieved from the N drive. Old versions of DFA Forms 720, 720(Ne), 720(Sp), 752A, 752A(Ne), 752A(Sp), 752, and 752HH must be recycled. A Certificate of Destruction is included in this SR.

Place a reorder through the DHHS Warehouse/Logistics via the District Office’s Quarterly Forms Order (QFO) when the supply of the new version of these forms is low.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

Section 134.03        Specified FANF Hardship Extension Criteria

Section 203.09        Interim Disabled Parent (IDP)

Section 209.13        Family Services Specialist (FSS) Determines Incapacity

Section 209.37        Verification of Deprivation

Section 808.05        Exemptions from Participation in NHEP

Section 808.07        Verification of Exemptions

Section 808.45        Referrals to the Medical Exemption Unit (MEU)

IMPLEMENTATION

Policy released in this SR is effective June 3, 2019.

An advance supply of BFA Forms 720, 752A, 752, and 752HH will be distributed to the District Offices at the end of May. The Spanish and Nepali translations of BFA Forms 720 and 752A can be ordered from the BFA Policy Unit on an as needed basis, or retrieved from the N drive. Old versions of DFA Forms 720, 720(Ne), 720(Sp), 752A, 752A(Ne), 752A(Sp), 752, and 752HH must be recycled. A Certificate of Destruction is included in this SR.

When the advance supply of BFA Forms 720, 752A, 752, and 752HH is low, resume regular ordering procedures through the DHHS Warehouse/Logistics via the District Office’s QFO.

CLIENT NOTIFICATION

Notification of the additional types of healthcare providers authorized to complete exemption and incapacity forms for FANF was published in the NH Rulemaking Register, Office of Legislative Services, on October 11, 2018. A public hearing on the Administrative Rules associated with this policy (He-W 606.30, He-W 628.02, and He-W 637.04) was held on November 6, 2018.

TRAINING

No special training is planned or needed.

FORMS MANUAL POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the revised manual topics released by this SR have been posted to the On-Line Manuals.

DISTRIBUTION

This SR will be distributed according to the electronic distribution list for BFA policy releases. This SR, and revised On-Line Manuals, will be available for agency staff in the On-Line Manual Library, and for public access on the Internet at www.dhhs.nh.gov/dfa/publications.htm, effective June 3, 2019. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Family Assistance Manual.

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