SR 10-19 Dated 06/10

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases a change in the procedures that conclude the initial eligibility interview for all programs of assistance. Previously, Family Services Specialists (FSS) would provide a colored folder containing various forms associated with the program for which the applicant was applying at the conclusion of an initial eligibility interview for Financial Assistance to Needy Families (FANF) financial or medical assistance, adult categories of financial or medical assistance, NH Child Care Scholarship, and the Food Stamp Program. These folders were informally called "end-of-interview packets." Effective with the release of this SR, these packets will no longer be provided at the end of an initial eligibility interview. Instead:

§   if the individual has internet access, FSS will provide the individual with new DFA Form 800W, Website Forms, which directs the applicant to the DHHS website to review the information associated with the programs of assistance for which the household is applying; or

§   if the applicant does not have internet access or refuses to sign new DFA Form 800W, FSS will provide certain required program-specific paper forms to the client for review.

POLICY

End-of-interview packets will no longer be provided at the end of an initial eligibility interview. Instead:

§   if the individual has internet access, FSS will provide the applicant with new DFA Form 800W, which directs the applicant to the DHHS website to review the information associated with the programs of assistance for which the household is applying; or

§   if the applicant does not have internet access or refuses to sign DFA Form 800W, FSS will provide certain required program-specific paper forms to the client for review.

DISTRICT OFFICE PROCEDURES

End of Interview packets will no longer be supplied on a monthly basis to the District Offices. All offices may dismantle their current supply of packets, at their convenience, so that the forms contained in the folders can be accessed as needed. All empty folders, once the forms and envelopes have been removed, can be returned to State Office in Concord, Attn: Linda White.

Currently, each applicant is asked if they have an email address during the interactive New HEIGHTS eligibility interview. If the applicant confirms ownership of an email address, it can be assumed that the applicant has internet access, even if the individual chooses not to share their email address with the Department at this time. At the end of the interview with an applicant who has access to the internet, FSS must provide new DFA Form 800W, Website Forms, to the individual. This form directs the applicant to the website below and lists the forms the applicant needs to review that are pertinent to the programs of assistance the household requested:

http://www.dhhs.nh.gov/DHHS/DHHS_SITE/apply.htm

As of the date of this SR, every applicant is expected to review (in numerical Form order):

§   DFA Form 77U, It Takes A Village. NH chose an option to expand categorical eligibility in the Food Stamp Program. By choosing this option, NH agreed to meet certain federal requirements associated with this option, and those requirements are currently being met via DFA Form 77U (see SR 09-05, dated 5/09 for further information);

§   DFA Form 215, Reporting Requirements Handout. DFA is mandated to provide all applicants with information about what information must be reported and when the information must be reported. Specific income information must be provided to Food Stamp applicants who have simplified reporting requirements. DFA meets this notification requirement via DFA Form 215;

§   DFA Form 800A, DFA Programs and Services Guide. DFA is federally mandated to provide all applicants with information about the resource limits for each program, basic eligibility requirements for each program, and how and when benefits are issued. DFA chooses to meet this requirement via the DFA Form 800A;

§   DFA Form 811R, Your Rights and Responsibilities. Federal law mandates that every applicant must be told about their rights and responsibilities. Providing DFA Form 811R meets this requirement.

§   Every applicant must be told about their rights to appeal Department decisions which they disagree with. Although DFA Form 811R adequately addresses the client’s rights to file an appeal, information related to the process for filing an appeal is met through the Administrative Appeal Unit (AAU) website or the AAU pamphlet (no form number listed).

Applicants for Food Stamp benefits are additionally expected to review (in numerical Form order):

§   DFA Form 77d, Food Stamp pamphlet; and

§   DFA Form 470, Food Stamp Program Change Report Form.

Applicants for FANF cash and medical assistance are additionally expected to review (in numerical Form order):

§   DFA Form 77a, FANF Pamphlet;

§   DFA Form 77i, Lump Sum Payments and FANF;

§   DFA Form 242, The 60-Month Lifetime Limit on FANF;

§   DFA Form 260, FANF Fact Sheet; and

§   DFA Form 757, How Your Benefits Will Change When You Go To Work.

Applicants of NH Child Care Scholarship are additionally expected to review the information on the Child Development Bureau (CDB) website, therefore two links to that website have been provided on the DFA website. Various billing and informational forms for both applicants and providers are provided on the CDB site, and information about Child Care Resource & Referral has also been provided for families looking for affordable and supportive child care in NH.

Applicants for the adult categories of cash and medical assistance are additionally expected to review (in numerical Form order):

§   DFA Form 77c, NH State Supplement Programs;

§   DFA Form 77s, Liens and Estate Claims Pamphlet; and

§   DFA Form 770, Reimbursement Agreement and Acknowledgement. This Form additionally requires a notarized signature as a condition of eligibility.

A verification checklist for nursing facility care, choices for independence, and home and community-based care is also listed on the website.

Applicants who do not have access to the Internet or who refuse to sign new DFA Form 800W, must be provided with the above paper version of the forms. For both applicants with access to the internet and applicants without access to the internet, the above forms represent the minimum forms that could be provided to each applicant based on the programs of assistance requested. Additional forms may be also required depending upon the household circumstances, e.g., a FANF applicant may also need DFA Form 773, Certification of Continued Absence, depending upon the type of FANF financial assistance being applied for. An APTD applicant may need certain forms related to medical disability, which an OAA applicant would not need.

DESCRIPTION OF NEW DFA FORM 800W, WEBSITE FORMS

New DFA Form 800W, Website Forms, is a 1-page, single-sided, 2-part NCR form used by FSS. The form is provided at the application eligibility interview to applicants who indicate that they have internet access. The purpose of the form is to:

§   provide the applicant with a paper copy of:

1. the website address that the applicant needs to access;

2. the list of forms that all applicants must review on the website; and

3. the list of program-specific forms associated with the assistance the applicant is requesting; and

§   provide protection to DFA in the event of an administrative appeal, as the signature and date on the form indicates that the FSS notified the applicant:

1.  that the website must be visited;

2. that the information contained on the website was required knowledge;

3. that the applicant would be held responsible for the information contained on the site; and

4. that paper copies of the information were available at any time.

FSS must review DFA Form 800W with the applicant when the applicant has indicated that they have internet access and the FSS is directing the applicant to the DFA website for program information. If the applicant:

§   signs and dates DFA Form 800W, give the white original to the applicant and retain the yellow copy in the DFA case file for three years from the date of signature; or

§   refuses to sign and date DFA Form 800W, give the applicant the paper copies of the forms.

Instructions for the form were created accordingly.

All offices will be provided with an initial supply of new DFA Form 800W by the effective date of this SR. Because this initial supply could not be printed as NCR, FSS will need to make copies of the form, once it has been signed, for the case file. If the office has progressed to scanning, the signed version merely needs to be scanned for the electronic case file. Once the initial supply has been exhausted, the DHHS Warehouse may be contacted in the usual manner for additional supplies.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

Section 109.03  Processing a Filed Application

Revised Adult Assistance Manual Topics

Section 109.03  Processing a Filed Application

Revised Food Stamp Manual Topics

Section 109.03  Processing a Filed Application

IMPLEMENTATION

As of the release of this SR, end-of-interview packets will no longer be delivered to the District Offices. Beginning with the release of this SR, FSS may begin directing applicants with internet access to the DFA website. All offices will be supplied with an initial supply of new DFA Form 800W, Website Forms, by the effective date of this SR. The Form 800W must be provided to all applicants being directed to the DFA website.

Paper versions of the forms listed in this SR must be provided to applicants without access to the internet or to applicants who refuse to sign new DFA Form 800W. Only those forms associated with the programs of assistance the applicant is requesting and the forms required for all applicants, need be provided.

CLIENT NOTIFICATION

Posters providing the DHHS website will be provided to all District Offices for the interview rooms and reception areas in the near future. No other special client notification is planned.

TRAINING

No special training is planned.

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 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 28, 2010. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Adult Assistance, Family Assistance, and Food Stamp Manuals.

DFA/JBV:s