SR 03-30 Dated 08/03

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases a statewide standard interview process. The following forms were revised or created accordingly:

·   new Form 217, How to Report a Change, and its instructions;

·   revised Form 800, Application for Assistance; and its instructions;

·   new Form 800A, Programs & Services Guide, and its instructions;

·   new Form 800AA, Programs & Services Guide Insert, and its instructions;

·   revised Form 811, Interview Worksheet, and its instructions;

·   revised Form 811R, Your Rights and Responsibilities, and its instructions; and

·   revised Form 811S, Statements of Understanding.

Form 77n, What’s Next?, Form 800HPT, Application for Assistance (Test Version), and their associated instructions have been obsoleted.

BACKGROUND

During this past year, several District Offices piloted implementing a 10-15 minute face-to-face conversation with the applicant prior to the New HEIGHTS interactive interview. It was found that this initial meeting helped to eliminate 26.8% of applicants who were grossly ineligible for assistance. As a result:

·   the applicant did not have to participate in a full 1 to 1½ hour interview to find out that he or she was not eligible for assistance;

·   the FSS did not have to conduct a full interview to discover that the applicant was not eligible for assistance; and

·   the FSS could better determine federal, state, or local programs for which the client could potentially be eligible and refer the client to those programs.

In conjunction with the Pilots, a worksheet was developed to assist FSS in asking key eligibility determining questions, as well as to provide FSS with a tool to document information that developed from the 10-15 minute conversation with the applicant.

Beginning May 1, 2003, a month-long pilot program allowed District Offices of various sizes an opportunity to use the newly revised forms in conjunction with the new interview procedures involving the face-to-face conversation with the applicant prior to the New HEIGHTS interactive interview, so that feedback regarding enhancement to the process could be incorporated prior to an official release of policy.

Results from the most recent pilot yielded suggestions for enhancements to the entire interview process, as well as comments for revisions to the forms being released in this SR.

POLICY

Beginning August 1, 2003, District Offices statewide will be implementing a new standard interview process involving a 10-15 minute face-to-face meeting with applicants as a preamble to the New HEIGHTS interactive interview, using the newly revised Form 800, Application for Assistance, and newly revised Form 811, Interview Worksheet. Additionally, new Form 800A, Programs & Services Guide, and new Form 800AA, Programs & Services Guide Insert, will be used to support the new statewide standard interview process.

STATEWIDE STANDARD INTERVIEW PROCEDURES

Beginning August 1, 2003 District Offices statewide will begin interviews with a 10 to 15 minute face-to-face conversation between the client and the FSS regarding the information provided on Form 800, Application for Assistance. There is no data entry into New HEIGHTS during this period of the interview. FSS will use Form 811, Interview Worksheet, during the conversation as a guide in asking key eligibility questions. New information collected during this meeting will be handwritten in the appropriate places on the form.

Step-by-step procedures from the moment the client walks into the District Office until the eligibility interview is complete, are as follows:

Support Staff

·   Greet the applicant and provide the individual with the newly revised Form 800, Application for Assistance. Do not provide any other program-specific forms.

·   When the applicant returns the completed Form 800, review it to ensure that the application has been signed and all questions answered completely. Lift up the coversheet and date stamp the application.

NOTE: All applicants must provide their name, address, signature and type(s) of assistance requested for the application to be valid.

·   Provide the applicant with Form 800A, Programs & Services Guide, which will contain Form 800AA, Programs & Services Guide Insert, and any additional needed forms such as:

-   the child support packet (Forms 725, 754B, 773, etc);

-   Form 177, Non-Medical Evaluation of Disability;

-   the EFT pamphlet;

-   the child care packet (Forms 251, 253, and AW-9); and/or

-   other forms that may pertain to the type of assistance requested.

·   Complete the "Agency Use Only" sections of the Form 800, looking up all individuals in the case. Print screens from the "Individual Information" tab under the "inquiry" folder for individuals open in another case, such as a child open in a relative’s case in another District Office, and attach the printouts to the Form 800.

·   If the client will be interviewed during normal interview hours, create a case file for the client or retrieve the client’s file from storage, place the client on the interview rotation list, and notify the FSS next in rotation.

·   If the client is unable to stay for an interview or has arrived after interview hours have ended:

-   review the Form 800 and ensure that the application has been signed and all questions are answered completely;

-   follow District Office procedures and review for expedited Food Stamps (see section below titled Expedited Food Stamps);

-   fill out the "Agency Use Only" section on the back of the coversheet of the Form 800, acknowledging DFA’s receipt of the application and when it was filed. Tear this sheet off and give it to the client;

-   provide the client with Form 800AN, Applicant Notice, requesting they return for an interview within 30 days with the listed proofs. Explain that the application will be denied if the client does not return for the interview within 30 days; and

-   do Client Registration (CR) according to District Office procedures. Do not print out the Form 800H at the conclusion of CR as the completed and signed Form 800 is the client’s official application for assistance. However, enter the Client Registration RFA number in the "Agency Use Only" section at the bottom of the last page of the application for future reference.

Expedited Food Stamps

Households that meet all eligibility criteria for the Food Stamp program may be entitled to expedited service if one of the following circumstances applies on the date of application:

·   gross monthly income is less than $150 and the countable liquid resources are $100 or less; or

·   rent/mortgage and utility expenses are in excess of the applicant’s combined monthly gross income and liquid resources.

NOTE: If resources exceed $2,000, or $3,000 if a household member is disabled or over the age of 60, the applicant is not eligible for Food Stamps.

If the applicant is eligible for expedited Food Stamps, a full interview will be conducted on the same day that the application is filed even if interview hours have ended for that day.

Family Services Specialist

During the 10-15 minute conversation with the applicant prior to the New HEIGHTS interactive interview, FSS ask key eligibility questions to determine if the applicant is:

·   not eligible for assistance;

·   potentially eligible for assistance; or

·   potentially eligible for some, but not all assistance requested.

At supervisor discretion, the FSS may begin Client Registration (CR) at his/her desk prior to the 10-15 minute face-to-face meeting.

NOTE: If it is not clear who CR should be under, do not begin CR before the 10-15 minute meeting with the client. All CR begun by the FSS must be completed by the FSS.

During the 10 to 15 minute face-to-face meeting with the client, use Form 811, Interview Worksheet, in conjunction with newly revised Form 800 to review client information. Use Form 811 to document any information that may help clarify the information that is on Form 800. Use the prompts and/or check boxes in the sections to help identify areas that need to be covered during the 10-15 minute meeting. Form 811 is mandatory and must be used with Form 800. Do not enter data into New HEIGHTS during the 10-15 minute meeting with the applicant.

Applicant is Determined NOT Eligible During the Face-to-Face Meeting

If the client is found ineligible for all programs of assistance requested after the 10-15 minute face-to-face conversation, then the FSS will:

·   discuss the reason(s) why the individual is ineligible for assistance. Refer the individual to a Community, State, or Federal Agency that may be able to assist them;

·   give the individual an opportunity to withdraw the application. Notify the client that if they withdraw, they may reapply at any time. Advise the client that by withdrawing the application, the individual forfeits the right to an Administrative Appeal;

·   deny the application in Client Registration, if the individual does not withdraw the application. If the application is denied, ensure that the individual understands that if he or she does NOT agree with the department’s decision, the individual has the right to request an Administrative Appeal through the Administrative Appeals Unit or the District Office;

·   begin Client Registration using the shortened application;

·   at the "Conclude Interview" screen, RFA Status Information, change Status to "Denied" and choose the most appropriate denial code. Statistics will be gathered by the system on the number and type of denials completed in CR each month. The current denial codes are:

-   Income Exceeds the Gross Income Limit;

-   No Eligible Member in AG;

-   Resources Exceed Limit;

-   Client Walked Out;

-   Interview Denial (Used by Healthy Kids Only); and

-   Client Withdrew.

·   add case comments to indicate why the applicant is not eligible;

·   print and close;

·   complete Form 811, Interview Worksheet, as needed, and file in the client’s record;

·   give the denied application to the Support Staff to be filed in the closed records; and

·   complete Client Registration prior to seeing the next applicant.

Applicant is Determined POTENTIALLY Eligible During the Face-to-Face Meeting

If it is determined during the 10-15 minute face-to-face meeting that the client is not eligible for one or some of the programs requested, then the FSS will:

·   let the client know which program(s) of assistance will be denied and the reasons for denial. Inform the client of their right to an Administrative Appeal if they do not agree with the decision of denial;

·   give the applicant the opportunity to partially withdraw their request for assistance for those programs for which they are not eligible, again advising them about forfeiting the right to an Administrative Appeal, and that they may reapply for those programs at any time;

·   complete the shortened Client Registration at the conclusion of the 10-15 minute face-to-face meeting, and proceed with the interactive interview in Application Entry; and

·   act upon every program of assistance requested by the client because Form 800 is an official application. If the applicant is eligible for some but not all programs, the FSS can do a partial withdrawal/denial of a program(s) requested in the Program of Assistance screen of New HEIGHTS. The following steps need to be completed for each program in which the client has been found to be ineligible. On the Program of Assistance, Request Assistance Summary screen:

-   choose the Request Assistance Details tab for the program which is being withdrawn or denied;

-   select "yes" for all programs checked off on the Form 800;

-   for denied programs, select "no" for "Individuals to be Included". Select "no" (request) and select an appropriate reason for each individual in the case;

-   continue this process for all programs that the applicant is withdrawing or being denied; and

-   finish the interview and run SFU/EDBC. This will deny the programs for which the client is found ineligible, pend the programs for which the client is found potentially eligible, and generate a NOD once the case is confirmed.

NOTE: If the client is applying for APTD, HCBC, HC-CSD or Nursing Facility Care, inform the client that another division will make an independent medical decision regarding eligibility.

COMPLETION OF INTERVIEW

At the completion of the interview, FSS will:

·   generate the "Eligibility Interview Summary" (EIS);

·   review the "Rights and Responsibilities" of the EIS;

·   review EACH statement on the EIS Signature Page;

·   have the client initial and sign in appropriate spaces on the EIS Signature Page;

·   sign and date in the spaces provided once the client has signed;

·   provide the applicant with the information packet. The contents of the packet will be based on the programs of assistance for which the client is found eligible, but will also include the following:

-   appropriate forms to be filled out by the client;

-   resources list (a list of other agencies that may be able to assist the client);

-   return envelope(s);

-   Form 65, Client Statement;

-   Form 217, How to Report a Change;

-   Form 756, Employment Verification Request;

-   Form 775, Rental Verification Request;

-   Form 776, Verification of Terminated Employment;

-   Pages 4 and 5 of Form 800 titled, Application for Assistance: Your Rights and Responsibilities;

-   NHEP information for TANF cash;

-   referrals;

-   the verification checklist; and

-   the FSS business card.

·   complete Form 811, Interview Worksheet, as needed, and file in client’s record.

Prior to ending the interview, review the following with the applicant:

·   Providing verifications. Review all of the verifications that need to be provided to the District Office. Emphasize that the verifications need to be provided as soon as possible so that a decision about eligibility can be made.

·   Reporting changes. Explain the types of changes the client needs to report and when, as well as the importance of reporting these changes to the District Office in a timely manner.

·   The NHEP referral process. If the client is applying for TANF cash assistance, ensure that the client is aware of the NHEP referral process, is given the NHEP information packet, and is referred to NHEP.

·   Who determines eligibility. If the client is applying for APTD, ANB, HCBC, HC-CSD or Nursing Home Care, explain that DFA determines eligibility based on financial and non-financial criteria, but another division will determine eligibility based on an independent medical decision.

·   The client’s right to appeal a decision. Explain to the client that if the client does not agree with DFA’s decision, then he or she has the option to file an appeal with the Administrative Appeals Unit or through the District Office.

FORMS NEEDED IN THE STATEWIDE INTERVIEW PROCESS

Form 800, Application for Assistance

Revised Form 800 will replace:

·   Form 800, Application, SR 98-51/November, 1998;

·   Form 800HPT, Application for Assistance, SR 02-30/August, 2002; and

·   Form 800, Application for Assistance, SR 03-09/July 2003, which was used only in the five District Offices conducting the Pilot, per SR 03-09, dated May 2003.

Revised Form 800 will become the official application for requests for assistance and will be:

·   provided to all District Office walk-in clients;

·   used in the simplified reapplication process; and

·   mailed to individuals who contact the District Office by telephone or mail, and do not want to come to the office to file an application on the same day. For these cases, mail the newly revised Form 800 on the same day that the individual contacts the District Office.

Form 800 has been revised to incorporate:

·   information on citizenship and the use of Social Security Numbers, based upon suggestions from the Office of Civil Rights;

·   user-friendly formatting such as highlighted areas to help determine expedited Food Stamps;

·   new FNS requirements regarding collection of applicant ethnicity and race; and

·   simplified readability for the client.

Form 800 is modeled after Form 800HPT with the addition of:

·   a coversheet that contains a brief description of programs administered by DFA; and

·   an informational sheet providing the client with written information about their rights and responsibilities along with pertinent warnings and advisories as required by Food and Nutrition Services (FNS).

The most apparent revisions to Form 800 are its layout and formatting, as well as the use of simplified language. In addition, the coversheet now serves as proof of application for the client. On the bottom of page 2 of the coversheet is a section for the worker to complete indicating the applicant’s name, programs requested, date, District Office, and signature of the worker. This page is provided to the client after the interview, or by support staff if the client cannot stay for an interview, and "locks in" the application date for the client.

Race and Ethnicity Collection

FNS requirements mandate the collection of race and ethnicity information from all applicants to ensure that benefits are distributed without regard to race, color, or national origin. The applicant may choose one ethnicity, but may choose more than one racial category. Although it is mandatory that DFA collect this information, it will remain voluntary for the applicant to provide the information. However, if the applicant does not voluntarily provide the information on the application, the FSS must complete this section using visual observation. When visual observation is used, only a single race need be collected, along with a single ethnicity.

Citizenship and Social Security Numbers

In an effort to promote the Food Stamp Program and minimize barriers for non-citizens applying for assistance, the US Department of Health and Human Services, Office of Civil Rights (OCR), in partnership with FNS, reviewed Form 800 and returned comments and suggestions on the collection of information pertaining to citizenship and social security numbers (SSNs). The changes in Form 800 support these efforts to maximize access of all programs to potentially eligible immigrants and families.

Citizenship or non-citizenship status as well as SSNs are only required of those individuals applying for assistance. However, Emergency Medicaid is available to non-citizens, regardless of their immigration status, to cover some emergency services including labor and delivery. SSNs are not needed to apply for Emergency Medicaid. Form 800 now more clearly indicates:

·   when non-citizens do not need to provide non-citizenship status;

·   who needs to provide an SSN;

·   how SSNs are used; and

·   when SSNs are necessary.

Expedited Food Stamps

Sections E, F, and G of the revised Form 800, have certain areas highlighted in gray to help assist support staff in determining the applicant’s potential eligibility for expedited Food Stamps. If the applicant is determined eligible for expedited Food Stamps, support staff will complete the gray box above section A to indicate that the applicant needs to be interviewed on that day, even if walk-in hours have ended for the day.

Form 811, Interview Worksheet

Newly revised Form 811 is modeled after Form 63, Change of Information, SR 84-28/April 1984, and will replace Form 811, Eligibility Determination Worksheet, SR 97-08/March 1997. Newly revised Form 811 has been designed to follow the driver flow of New HEIGHTS, making it simpler to capture the information necessary to assess an applicant’s eligibility.

FSS will use revised Form 811 during the 10-15 minute meeting that occurs prior to the New HEIGHTS interactive interview. Form 811 is used in conjunction with newly revised Form 800 to capture additional information during the meeting. Use of Form 811 during the 10-15 minute face-to-face meeting prior to the New HEIGHTS interactive interview is mandatory.

Form 811 was designed to be:

·   a guide for the FSS interviewer. Form 811 provides prompts and check boxes to aid in asking key eligibility determining questions during the 10-15 minute meeting prior to the New HEIGHTS interactive interview;

·   an extension of Form 800. Form 811 allows room for capturing additional, unique, or unusual circumstances of the case that are not written anywhere else on Form 800; and

·   a review tool for the supervisor. Form 811 allows the supervisor to review cases quickly to see if interviews were performed thoroughly.

New Form 800A, Programs & Services Guide, and 800AA, Programs & Services Guide Insert

New Form 800A, Programs & Services Guide, is a booklet designed to inform individuals about:

·   the programs and services DFA offers;

·   how benefits are delivered;

·   proofs that will be needed to determine eligibility;

·   the processing times and how applicants will be informed of the status of their application;

·   the TANF 60-month lifetime limit; and

·   what is expected of recipients.

Form 800A will be given to the applicant by support staff when the application is returned. This will give the applicant an opportunity to review programs and services offered by DFA prior to the interview.

New Form 800AA, Programs & Services Guide Insert, is a half sheet, double sided form containing general resource information. This form is designed to direct individuals to other sources of assistance outside of DFA.

Upon distribution of the 800A and 800AA from Graphic Services, this form will replace Form 77n, What’s Next, SR 00-33/July 2000.

New Form 217, How to Report a Change

New Form 217, How to Report a Change, provides instructions to the client on how to report changes that would affect their case. The form provides examples of the types of changes that need to be reported as well as information that is required by the District Office regarding those changes and will be inserted into the new informational packet provided at the end of the eligibility interview. This form was developed to help:

·   the client know what to report and when to report it; and

·   the FSS to retrieve information on changes and act on those changes reported by the client in a timely manner.

New Form 217 is being released in template format. From that template, individualized forms have been developed for each District Office to incorporate the appropriate phone number and address to which the client can report changes and send information. When reordering this form, order Form 217(District Office #). For example, Rochester is District Office #17. When reordering, Rochester will order Form 217(17) to indicate the need for the Rochester personalized form. Until these forms are printed, an initial supply will be provided to all District Offices.

Form 811R, Your Rights and Responsibilities, and Form 811S, Statements of Understanding

Form 811R, dated 08-03, and Form 811S, dated 08-03, have been updated to reflect suggestions and comments received from FNS and the Office of Civil Rights (OCR).

Clarification regarding notifying immigrant families of when assistance can affect their immigration status was added to Form 811R. In addition, the non-discrimination statement was updated to provide federal addresses and numbers for clients to use, as desired, during the complaint process.

Furthermore, a statement regarding the client’s acknowledgement that the Domestic Family Violence Option was explained, and is understood, was added to Form 811S.

POLICY MANUAL REVISIONS

Revised Adult Assistance Manual Topics

Section 109.01   Filing an Application

Section 109.03   When the Application is Filed

Revised Family Assistance Manual Topics

Section 109.01   Filing an Application

Section 109.03   When the Application is Filed

Revised Food Stamp Manual Topics

Section 109.01   Filing an Application

Section 109.03   When the Application is Filed

IMPLEMENTATION

All procedures released in this SR are effective August 1, 2003.

Beginning August 1, 2003, use the newly revised Form 800, Application for Assistance, for the official application for requests for assistance. The District Offices must provide this form to all walk-in clients, mail to all clients requesting an application, and use for all add a program requests as well as for the simplified reapplication process. District Offices will continue to accept incoming applications that have been completed using:

·   Form 800, SR 98-51/November 1998;

·   Form 800HPT, SR 02-30/August 2002; and

·   Form 800, SR 03-09/July 2003.

Effective August 1, 2003, District Offices must recycle current supplies of these forms (see the certificate of destruction at the end of this SR).

Form 811 must be completed for all new applications and add a program requests. However, it is the supervisor’s discretion regarding the use of Form 811 in redeterminations.

The District Offices have received an initial supply of the revised versions of Form 800 and Form 811 in preparation for the implementation date. State Office will continue to supply these forms until the supply of forms arrives from Graphic Services. At that time, regular ordering procedures through logistics will resume.

Form 800A, Program & Services Guide, will obsolete Form 77n, What’s Next?, SR 00-33/July 2002. Continue to use Form 77n until the first shipment of Form 800A arrives at the District Office. At that time, destroy current stocks of Form 77n.

The District Offices have received an initial supply of new Form 217, How to Report Changes, in preparation for the implementation date. State Office will continue to supply these forms until the supply of Form 217 arrives from Graphic Services. At that time, regular ordering procedures through logistics will resume.

Paper versions of Form 811R, Your Rights and Responsibilities, and Form 811S, Statements of Understanding, have been updated. New HEIGHTS versions of these forms will be updated in the near future. Paper versions of the forms are back-up to the New HEIGHTS versions of the forms and are used in the event of system failure.

CLIENT NOTIFICATION

No special notification is necessary.

TRAINING

The District Offices will be trained by Mickie Grimes, Field Operations Supervisor. No additional training is planned, as the Managers of Administration and the District Office Supervisors have been active participants in the development of the forms and process. Questions and concerns about the new interview process should be directed to Mickie.

FORMS POSTING INSTRUCTIONS

DISPOSITION

This SR may be destroyed or deleted after its contents have been noted and the SR has been posted to the On-line manual.

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/DHHS/DFA/LIBRARY, effective September 1, 2003.

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/DMS:s

T:\FAMILY\DFA\POLICY\Group\SRPKG\2003srs\SR 03-30 800 Final\SR 03-30.doc

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CERTIFICATE OF DESTRUCTION

I certify that all copies of the following forms have been destroyed:

·   Form 77n, dated 07/00, SR 00-33 (Only after receipt of Form 800A, dated 08/03, SR 03-30);

·   Form 800, dated 11/98, SR 98-51; and

·   Form 800HPT, dated 08/02, SR 02-30.

For the 5 District Offices involved with the May 2003 Pilot, the following forms must also be destroyed:

·   Form 800, dated 07/003, SR 03-09; and

·   Form 811, dated 07/03, SR 03-09.

Office Manager:    District Office     

Return this certificate to DHHS Stock Control, 6 Hazen Drive, Concord, NH 03301, after the instructions in the SR have been carried out.