SR 12-33 Dated 12/12

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

SUMMARY

This SR releases revisions to the following forms:

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

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

This SR additionally releases the obsolescence of DFA Form 800P(Bo), Bosnian Version of DFA Form 800P, and DFA Form 800PR(Bo), Bosnian Version of DFA Form 800PR.

DESCRIPTION OF REVISIONS MADE TO FORMS

The Office of Special Investigations (OSI) brought to DFA’s attention an incorrect statement on both DFA Form 800P and DFA Form 800PR. Pursuant to RSA 167:17-a, the Department does not have authority to recover erroneously received Medicaid when the erroneous receipt of medical assistance was due to a mistake the Department made in processing the case. Because of this, the following text was eliminated from both the DFA Form 800P and DFA Form 800PR and the Spanish translations of these forms, as indicated by the strikethrough formatting below:

You are required to pay back any benefits or services received in error, regardless of whether we made a mistake in processing your case or you made a mistake in the information you provided, or failed to provide, to us.

A text change only was required; current Department procedures, as described in Family Assistance Manual (FAM) 623, RECOUPMENT OF MEDICAL ASSISTANCE, require no changes as DHHS has never pursued recovery of medical assistance received erroneously due to agency error.

DFA Form 800P(Bo), Bosnian Version of Form 800P, and DFA Form 800PR(Bo), Bosnian Version of Form 800PR, are obsolete with the release of this SR. The Office of Minority Health and Refugee Affairs (OMHRA) has informed DFA that the Bosnian population in NH has greatly diminished. Because of this, OMHRA indicated that there is no longer a need for DFA forms to be translated into Bosnian. As such, DFA Form 800P(Bo) and DFA Form 800PR(Bo) will not be updated with the changes made to the English version but instead are obsolete. A Certificate of Destruction has been included with this SR.

Workers should continue to use the old English and Spanish versions of DFA Form 800P and DFA Form 800PR until the supply is exhausted. The new paper versions of DFA Form 800P and DFA Form 800PR will be available for use when the current supplies are depleted. The Forms are also being translated into Nepali and will be released under separate cover once the documents have been returned from the translators. Reorder using the current forms ordering system. The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database. DFA Form 800P is also available on the DHHS website.

POLICY MANUAL REVISIONS

Revised Family Assistance Manual Topics

Glossary  R-words

IMPLEMENTATION

District Office staff must deplete the old English and Spanish versions of DFA Form 800P and 800PR before the new version is printed. Once the current supply of DFA Form 800P and DFA Form 800PR is exhausted, the new versions will be available from the DHHS warehouse in the usual manner, via the Quarterly Forms Order (QFO). The forms are also available electronically, for Department staff only, on the Lotus Notes Family Services Database. DFA Form 800P is also available on the DHHS website.

CLIENT NOTIFICATION

No special client notification is planned or needed.

TRAINING

No special training is planned or needed.

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 December 31, 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