SR 02-16 Dated 04/02

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases New Forms 760, Medicaid In and Out Spenddown Log, and 760(i), Instructions to Form 760.

BACKGROUND

DFA held a refresher Medicaid In and Out training in February 2002. As a result of the training, District Offices requested that a form be created on which they could record the client’s medical expenses and advise the client of which expenses were used to meet the spenddown liability.

POLICY

Form 760, Medicaid In and Out Spenddown Log, is a 2-part NCR form which records the client’s medical expenses and how the spenddown was met. It must be given or mailed to the client when the client’s 1-month or 6-month spenddown has been met. District Offices should encourage, but not require, clients to share the information on the form with providers so that the providers will be aware of the balance of bills that can be submitted to Medicaid for payment processing. Clients cannot be required to share the information on the form with their providers due to confidentiality issues.

Form 760(i) provides detailed instructions on how to complete Form 760, and is attached for reference.

IMPLEMENTATION

Form 760 is effective April 1, 2002. District Offices were provided with a draft version of Form 760 on February 25, 2002, and may continue to use it until finalized Form 760 is available from print. Finalized Form 760 will be distributed under separate cover. Upon receipt of the finalized form, the draft version must be recycled or destroyed. No Certificate of Destruction is included in the SR, because the draft version of Form 760 was not officially released by SR.

CLIENT NOTIFICATION

Clients will be advised of the new procedures at reapplication or when bills have been submitted and the spenddown has been met.

TRAINING

In and Out training for DFA field staff, the Medicaid Administration Bureau, and the Office of Quality Assurance was held from February 7 to February 26, 2002.

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.state.nh.us/PMIndex.htm, effective May 1, 2002.

This SR will be distributed under separate cover to all hard copy holders of the Forms manual.

DFA/SJC:s