SR 04-04 Dated 05/04

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases:

§   modifications and enhancements to the Form 811H, Eligibility Interview Summary, which includes Your Rights and Responsibilities and Statements of Understanding pages, generated at the end of the initial application interview for all programs of assistance; and

§   new redetermination/recertification Form 800HR, New HEIGHTS-generated Application for Assistance, and its instructions; the 800HR is only generated during face-to-face District Office recertifications/redeterminations for all programs and can be used to add a program during a redetermination/recertification interview.

Paper Form 811R, Your Rights and Responsibilities, and paper Form 811S, Statements of Understanding, were updated to reflect the changes made to New HEIGHTS-generated Form 811H.

In addition, this SR releases:

§   a related procedure clarification regarding the application process for nursing facility care. All individuals applying for nursing facility care must complete the paper Form 800, Application for Assistance, and participate in a personal interview;

§   changes to the initiation coding to allow the New HEIGHTS-generated Bank Account and Life Insurance verification letters to be printed online; and

§   the suspension of Form 800H, the New HEIGHTS-generated Application, also known as the "HAF." Although Form 800H is still available in New HEIGHTS, do not use it; Effective May 1, Form 800H is no longer an official application.

BACKGROUND

Enhancements to Form 811H, Eligibility Interview Summary, companion to Form 800, Application for Assistance that is used at initial application, were established as a priority at the 2003 Spring Leadership Conference. District Office Staff requested a "single-packet" EIS generated in the order of the actual interview process for the following reasons:

§   The eligibility interview summary (EIS) document is, at minimum, seven pages long. When printing the EIS at the end of the interactive interview, Family Services Specialists (FSS) waited for the whole packet to print then shuffled pages to align the printed pages with the actual flow of the end-of-interview summary in which the individual’s rights and responsibilities are discussed, all information provided to the FSS during the interview is confirmed, and the Statements of Understanding are reviewed and signed, acknowledging comprehension of and certifying accuracy of all information. FSS wanted to eliminate the need to reorganize the printed packet and requested that the EIS be revised to align with the interview flow.

§   At the time the 2003 Spring Leadership Conference was held, New HEIGHTS-generated verification forms could not be generated online without specific information being entered. The AE0012, Employment Verification Request, for example, could not be generated from New HEIGHTS without the employer’s address being entered. Although applicants and recipients were often able to provide the name of their place of employment, the individual was not always able to provide an address. Consequently, the verification form could not be generated from New HEIGHTS. Because of this, FSS wanted the EIS to additionally contain blank verification forms that would print at the end of the interview in a single packet with the EIS. Because New HEIGHTS had already initiated the process of allowing the Employment, Rental, and Terminated Employment letters to be printed online with no address necessary, it was subsequently decided that during the EIS project:

-   the "single packet" EIS in which blank forms were printed out along with the EIS was not necessary if FSS had the ability to print needed verification forms online when at the pertinent New HEIGHTS screen; and therefore,

-   revisions to the initiation coding allowing print capabilities at the pertinent New HEIGHTS screen with minimal information entered for the two remaining letters, the Life Insurance and the Bank Verification letters, would be added to the EIS enhancement project.

POLICY

Review and obtain signatures on the New HEIGHTS-generated:

§   Form 811H, Eligibility Interview Summary, at the conclusion of the initial application interview; and

§   Form 800HR, Application for Assistance, at the conclusion of an in-office recertification or redetermination interview.

New Form 800HR is an official application and must be signed accordingly for an individual’s redetermination or recertification to be considered complete.

§   Form 800H, also known as the HAF, is still available in New HEIGHTS, but is no longer an official application. Do not use unless otherwise instructed by State Office.

RELATED PROCEDURE CLARIFICATION REGARDING APPLICATION FOR NURSING FACILITY CARE

Applicants for nursing facility care do not have special application procedures and are to follow the same application for assistance process as all other applicants:

§   Form 800, Application for Assistance, must be completed and signed by all nursing facility applicants or the applicant’s authorized representative; and

§   a personal interview must be conducted.

DISTRICT OFFICE PROCEDURES

At Application

At the end of the interactive eligibility interview, initiate, print, and discuss the Form 811H, Eligibility Interview Summary, with all applicants. If the client is in the office with the FSS, the explanation of Your Rights and Responsibilities and the initials and signatures required on the Statements of Understanding page will occur during the face-to-face interview. If the personal interview occurs via phone, send the EIS to the person’s home with a postage-paid pre-addressed envelope. The applicant retains Your Rights and Responsibilities while the summary and Statements of Understanding, with all necessary signatures, must be returned to the District Office where both are retained in the District Office case record for three years from the date of completion.

At Recertification/Redetermination

For in-office recertifications/redeterminations only, print new Form 800HR, New HEIGHTS-generated Application for Assistance, at the conclusion of the interactive interview and:

§   review all material in the packet;

§   provide the initial informational pages and Your Rights and Responsibilities to the client for the client’s records.

§   obtain the required initials and signatures on the Statements of Understanding page;

§   retain the summary and Statements of Understanding, with all necessary signatures, in the District Office case record for three years from the date of completion.

The "Application Date" field on the Form 800HR is autopopulated with the date that the form is actually printed. Once signed, Form 800HR is a complete application and the individual’s application date is "locked-in." In the event that an individual must leave during the recertification/redetermination process, the application date will not be locked-in without a signed Form 800HR, or a signed paper Form 800, Application for Assistance, with name, address, and program(s) of assistance requested, indicated. If the individual cannot stay, explain the effect on their benefits and offer the paper application for the individual to complete.

Note: Procedures remain unchanged for individuals eligible for mail-in redeterminations. The new process involving Form 800HR applies to in-office recertifications/redeterminations only.

FORMS REVISIONS

Form 800H, New HEIGHTS-Generated Application

Although the Form 800H, also known as the HAF, will be retained in New HEIGHTS, it is no longer an official application. Do not use unless otherwise instructed by State Office. No Certificate of Destruction is included in the SR because this form is suspended, not obsoleted.

Form 800HR, New HEIGHTS-Generated Application for Assistance

New Form 800HR, New HEIGHTS-generated Application for Assistance, is an official application for continued assistance used during District Office recertifications and redeterminations only.

Food Stamp recipients are certified for specific periods of time at the end of which the individual must reapply for assistance to continue receiving benefits. New Form 800HR was created to provide an official application for individuals receiving Food Stamp benefits and individuals adding a program during recertification/redetermination. This new form gathers the needed signatures required for an application to be considered "complete" per SR 03-30, dated August 2003 and SR 03-43, dated September 2003, and supplies mandated client information to all individuals who are considered to be applicants during the recertification or redetermination process.

Note: Continue using the form applicable to the program of assistance for individuals eligible for mail-in redeterminations.

Form 800HR consists of:

§   informational cover pages, similar to the first pages of the paper Form 800, Application for Assistance;

§   Your Rights and Responsibilities;

§   detailed case information gathered during the interview; and

§   the Statements of Understanding signature page.

At the conclusion of the recertification/redetermination eligibility interview:

1. Select the "Initiate" button on the "Print EIS" tab and Form 800HR will generate automatically from New HEIGHTS.

2. Review Form 800HR with the client.

3. Give the initial informational pages and Your Rights and Responsibilities to the client after discussing the contents and answering all questions.

4. If errors are discovered or other changes requested, reenter New HEIGHTS screens as appropriate, make the required changes, and reprint Form 800HR.

5. Review each applicable statement on the Statements of Understanding page and have the individual initial each statement in the space indicated. If the individual is not receiving assistance from a certain program and has not applied to receive assistance for this program during recertification or redetermination, "N/A" and initial the statement if the statement is not discussed with the client. If the statement is discussed with the client, even if the client is not applying for or receiving assistance from the program, have the client initial the statement in the space indicated.

6. Require the individual or authorized representative to sign and date where indicated on the Statements of Understanding page.

7. Sign and date in the "Employee" space provided on the Statements of Understanding page certifying that the client has been given the opportunity to review Form 800HR and that Your Rights and Responsibilities has been explained and provided to the client.

8. Retain in the District Office case record for three years from the date of completion.

New Form 800HR(i), Instructions for Form 800HR, incorporates the procedures identified above.

Form 811H, Eligibility Interview Summary

Based upon the 2003 Spring Leadership Conference request to have the Form 811H, Eligibility Interview Summary, revised, the following changes were made:

§   the "look" of the document was altered to add clearly defined tables and sections, and to align it with the flow of the New HEIGHTS interview. At the request of Conference members, Form 125, Transfer of Client Records, was used as a model;

§   fields will no longer be displayed if there is no value in HEIGHTS. Previously, if the household incurred no medical expenses a blank field was displayed in the summary. Now, if no value has been entered into New HEIGHTS the field will not be displayed at all;

Exception: When an individual declares that no one in the household has any form of income, the following text will display: "Household stated that no one has any income." A similar statement will display for a declaration of no resources or no expenses;

§   any information that end dates prior to the current date will no longer be displayed in the summary. Future end-dated information, however, will continue to be displayed;

§   the field "NH resident less than 2 years" has been removed from the "Household Member" section;

§   the marital status for individuals under the age of 12 will not be displayed in the "Household Member" section;

§   work, home, and message phone numbers, if collected, will be displayed in the "Household Address" section;

§   type and amount will display for income and each resource in the "Income Information" and "Resource Information" sections;

§   vehicle type, make/year, and Fair Market value will display for vehicles in the "Resource Information" section;

§   the employer’s name and the 4-week average will display as the "Monthly Average" in the earned income row in the "Income Information" section; and

§   the premium amount and the name of the company for Third Party Liability will display under medical insurance coverage in the "Additional Information" section.

Form 811H is generated at the end of the initial application eligibility interview, and the printed version was revised to align with the flow of the interview. Pages are now ordered as follows:

§   Your Rights and Responsibilities will be printed as the fist page of the Form 811H;

§   the summary of the information the individual provided to the FSS during the interactive interview will follow; and

§   the Statements of Understanding page will complete the packet.

At the conclusion of the applicant’s eligibility interview:

1. Select "Initiate" from the "Print EIS" tab and Form 811H will be generated automatically from New HEIGHTS.

2. Review Form 811H with the applicant.

3. Give Your Rights and Responsibilities to the applicant after discussing the contents and answering all questions.

4. If errors are discovered or other changes requested, reenter New HEIGHTS screens as appropriate, make the required changes, and reprint Form 811H.

5. Review each applicable statement on the Statements of Understanding page and have the applicant initial each statement in the space indicated. If the individual is not applying for assistance from a certain program, "N/A" and initial the statement if the statement is not discussed with the applicant. If the statement is discussed with the applicant, even if the individual is not applying for the program, have the applicant initial the statement in the space indicated.

6. Require the applicant or authorized representative to sign and date where indicated on the Statements of Understanding page.

7. Sign and date in the "Employee" space provided on the Statements of Understanding page certifying that the applicant has been given the opportunity to review Form 811H and that Your Rights and Responsibilities has been explained and provided to the applicant.

8. Retain Form 811H in the District Office case record for 3 years from the date of completion.

Form 811H(i), Instructions for Form 811H, was updated accordingly.

Form 811R, Your Rights and Responsibilities

Text changes and minor revisions to formatting were made to paper Form 811R, Your Rights and Responsibilities, as follows:

§   the section describing the TANF lifetime limit on receipt of financial assistance was moved to the top of the form and expanded to indicate that there is no time limit on State Supplement Programs, Medical Assistance, Food Stamps, or child care assistance and that the cash assistance received while the individual was a child does not count towards the TANF lifetime limit;

§   the "Reporting Changes" section was updated to include the simplified reporting requirements released by SR 04-16, dated June 2003;

§   the "Notice to Immigrant Families" section was moved to the top of the second page and the language was simplified; and

§   the fine for violating the Food Stamp Act was increased to $250,000 in accordance with 7 CFR 271.5(b).

The above changes were made to the paper version of Form 811R and to the first pages of the Form 800HR, New HEIGHTS-generated Application for Assistance, and Form 811H, Eligibility Interview Summary. Form 811R(i), Instructions for Form 811R, was updated to describe the electronic generation of the information contained in the paper version of Form 811R.

Form 811S, Statements of Understanding

Based upon requests by FSS and members who participated in the EIS Enhancement project meetings, Form 811S, Statements of Understanding, was slightly altered to group like statements together. For example, statements that apply to all applicants and recipients were presented first, followed by:

§   statements that apply to receipt of cash assistance;

§   statements that apply to receipt of cash assistance and Food Stamps;

§   statements that apply to receipt of Food Stamp benefits-only; and

§   concluding with statements that apply only to receipt of Medical Assistance.

The above changes were made to the paper version of Form 811S as well as to the final pages of the Form 800HR and Form 811H. Form 811S(i), Instructions for Form 811S, was updated to describe the electronic generation of the information contained in the paper version of Form 811S, and the changes made to initialing the specific statements pertinent to the individual’s requested programs of assistance.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

PART 109   APPLICATION PROCESS

Section 109.03   When the Application is Filed

Section 109.07   Reuse of Forms 800, 800HR, and 800P After Denial or Closing

PART 119   JOINT APPLICATIONS

Section 123.01   Initiation of Medical Assistance

PART 129   PENDING INFORMATION

Section 161.05   Processing Redeterminations/Recertifications

Section 161.07   Termination at Redetermination/Recertification

PART 165   TERMINATION OF FINANCIAL ASSISTANCE

Section 220.05   Application for Healthy Kids-Silver Medical Insurance

PART 223   CHILDREN WITH SEVERE DISABILITIES

Section 223.03   Required Verification

PART 225   HOME CARE FOR CHILDREN WITH SEVERE DISABILITIES (HC-CSD)

Section 225.03   Required Verification

Section 305.03   Declaration of Citizenship

Revised Adult Assistance Manual Topics

PART 109   APPLICATION PROCESS

Section 109.03   When the Application Is Filed

Section 109.09   Reuse of Forms 800, 800HR, and 800Q After Denial or Closing

PART 123   PENDING INFORMATION

PART 155   REDETERMINATION

Section 155.05   Required Verification for Redetermination

Section 305.01   Declaration of Citizenship or Alien Status

Glossary   A-words

Glossary   M-words

Revised Food Stamp Manual Topics

PART 109   APPLICATION PROCESS

Section 109.03   When the Application Is Filed

Section 109.07   Reuse of Form 800 and 800HR After Denial or Closing

Section 111.03   AR Signature Required

PART 119   JOINT APPLICATIONS

Section 305.03   Declaration of Citizenship

IMPLEMENTATION

The policy and procedures released by this SR are effective May 1, 2004.

The paper versions of Form 811R, Your Rights and Responsibilities, and Form 811S, Statements of Understanding, will be used until the current supply has been exhausted, at which time the new versions will be printed. The New HEIGHTS-generated versions of Form 800HR and Form 811H will be generated beginning May 1, 2004.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned or needed.

FORMS 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 Division of Family Assistance 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 http://www.dhhs.nh.gov/DHHS/DFA/LIBRARY, effective June 7, 2004.

This SR, and printed pages with posting instructions, will be distributed under separate cover to all hard copy holders of the Adult Assistance, Family Assistance, Food Stamp, and Forms Manuals.

DFA/JBV:s