SR 12-30 Dated 08/12

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases changes in the verification process for deprivation due to continued absence of a parent for the Financial Assistance to Needy Families (FANF) program. FANF applicants and recipients must continue to complete DFA Form 773, Certification of Continued Absence, as a condition of FANF eligibility at application, when appropriate (such as when the 30-days have been broken), and whenever continued absence is questionable. However, the completion of DFA Form 773 is no longer required at redeterminations. Instead, by signing revised DFA Form 800R, Application for Continued Eligibility for Financial, Medical, Child Care and Food Stamp Benefits, at every redetermination, the recipient who is receiving FANF because of deprivation due to continued absence of a parent will now be:

·   certifying the continued absence of all responsible parents associated with their FANF case; and

·   agreeing to immediately notify DHHS if any responsible parent returns to the home.

This change required revisions to DFA Form 773(i), Instructions for DFA Form 773, in addition to the revisions to DFA Form 800R.

Additionally, unrelated revisions have been made to the following forms:

·   DFA Form 11, Authorization to Release Information, and its associated instructions;

·   DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and its Bosnian and Spanish translations, DFA Forms 800P(Bo) and DFA Form 800P(Sp); and

·   DFA Form 800PR, Renewal Application For Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and its Bosnian and Spanish translations, DFA Forms 800PR(Bo) and DFA Form 800PR(Sp).

POLICY

DFA Form 773, Certification of Continued Absence, no longer needs to be sent out at redeterminations for Financial Assistance to Needy Families (FANF) recipients who are receiving FANF because of deprivation due to continued absence of a parent. Instead, the statements of understanding section of DFA Form 800R, Application for Continued Eligibility for Financial, Medical, Child Care and Food Stamp Benefits, has been revised to include the following statement:

I understand that deprivation of parental support and care is a condition of eligibility for FANF. Additionally, if I get FANF because of deprivation due to continued absence of a parent, my signature below also means that I certify the continued absence of all responsible parents associated with my FANF case, and I agree to immediately notify DHHS if any responsible parent returns to my home.

In addition to the new statement of understanding added to DFA Form 800R, the form was also revised as follows:

·   The form will no longer be printed on blue paper. The darkness of the blue paper combined with certain shaded sections on the form were causing readability issues when the form was scanned for the electronic case files. Instead, the form will now be printed on white paper but will still contain blue headers to continue to visually flag users of the paper form that the form is associated with a redetermination.

·   Section 1 of the form was altered to replace the date of birth (DOB) field with a field to collect the casehead’s social security number.

·   Section 2 of the form was revised to add the casehead to the list of members in the household so that the casehead’s DOB could continue to be collected, but primarily so that workers will be able to collect the student status of the casehead.

Workers should continue to use the old version of DFA Form 800R until the supply is exhausted. The new paper version of DFA Form 800R will be available for use when the current supply is depleted. Reorder using the current forms ordering system. The form is also available internally, for Department staff only, on the Lotus Notes Family Services Database.

DFA Form 773(i), Instructions for DFA Form 773, was also updated to remove the requirement that DFA Form 773 be sent out at redeterminations. No changes were required to DFA Form 773.

UNRELATED DESCRIPTION OF REVISIONS MADE TO FORMS

DFA Form 11, Authorization to Release Information

There are no changes in how DFA Form 11 will be used by DFA. However:

·   DFA Form 11 will no longer be printed as a 3-PART, no-carbon-required (NCR) form. Due to the availability of Electronic Document Imaging in all District Offices, NCRs are no longer required. Instead, when using the new version of the form, Family Services Specialists (FSS) will scan the form once it is completed, and then provide the original to the individual, agency, or institution from whom information is being requested; and

·   the fill-in field associated with the expiration date of the authorization was eliminated to simplify the completion of the form. Text will now simply indicate that the authorization expires 12 months from the date the form is signed.

The instructions for this form were updated accordingly.

Workers should continue to use the old version of DFA Form 11 until the supply is exhausted. The new version of DFA Form 11 will be available for use when the current supply is depleted. Reorder using the current forms ordering system. The form is also available externally on the DHHS website, and internally, for Department staff only, on the Lotus Notes Family Services Database.

DFA Form 800P, Application for Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW), and DFA Form 800PR, Renewal Application For Children’s Medicaid (CM) and Medical Coverage for Pregnant Women (MCPW)

There are no changes in how DFA Forms 800P and 800PR will be used by DFA. However:

·   both forms were revised to add back in parental information for the additional children in the household. This information was originally removed in July of 2012 but was determined to be necessary for the eligibility process so was added back to both forms to reduce the need for FSS to make follow-up phone calls to the family. This additional text caused both forms to expand from 3 back-to-back pages to 4 back-to-back pages; and

·   both forms were additionally revised to change the header of the section collecting information about pregnancy. To assist users of the form and help ensure the user only completes this section if necessary, the header for this section will now read as follows: FOR PREGNANT WOMEN ONLY – PLEASE COMPLETE IF CURRENTLY PREGNANT OR IF YOU WERE PREGNANT IN THE LAST 3 MONTHS.

The Spanish and Bosnian versions of both forms were revised accordingly and have been included in this release.

Workers should continue to use the old versions of DFA Forms 800P and 800PR and their translations until the supply is exhausted. The new versions of DFA Form 800P and 800PR will be available for use when the current supply is depleted. Reorder using the current forms ordering system. DFA Form 800P and its translated versions are also available externally on the DHHS website, and both forms and their translations are available internally, for Department staff only, on the Lotus Notes Family Services Database.

NEW HEIGHTS SYSTEMS PROCEDURES AND IMPLEMENTATION

The statements of understanding section of the NH EASY redetermination process has been updated to include the following text:

I understand that deprivation of parental support and care is a condition of eligibility for FANF. Additionally, if I get FANF because of deprivation due to continued absence of a parent, my signature also means that I certify the continued absence of all responsible parents associated with my FANF case, and I agree to immediately notify DHHS if any responsible parent returns to my home.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

Section 209.37  Verification of Deprivation

IMPLEMENTATION

The policy in this SR is effective August 31, 2012.

Workers should continue to use the old versions of DFA Form 11, 800P, 800PR, 800R, and associated translations of 800P and 800PR, until the supply is exhausted. The new paper versions of DFA Form 11, 800P, 800PR, 800R, and associated translations, will be available for use when the current supply is depleted. Reorder using the current forms ordering system. DFA Forms 11, 800P, and the translations of 800P, are also available externally on our website and DFA Forms 11, 800P, 800PR, 800R, and associated translations, are available internally, for Department staff only, on the Lotus Notes Family Services Database.

CLIENT NOTIFICATION

No 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 www.dhhs.nh.gov/DFA/publications.htm, effective October 1, 2012. 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 and Forms Manuals.

DFA/JBV:s