SR 13-35 Dated 10/13

 

STATE OF NEW HAMPSHIRE

INTER-DEPARTMENT COMMUNICATION

 

FROM OFFICE OF THE DIRECTOR, DFA:

Terry R. Smith

DFA SIGNATURE DATE:

October 8, 2013

AT (OFFICE):

Division of Family Assistance

TO:

District Office Supervisors

 

SUBJECT:

Release of the New Medical Assistance Manual (MAM)

EFFECTIVE DATE:

October 28, 2013

 

 

SUMMARY

 

This SR releases new Medical Assistance Manual (MAM) which, when fully completed, will contain the official Division of Family Assistance (DFA) policy governing the administration of the following categories and programs:

 

·      Medicaid and insurance for children through the Children’s Health Insurance Program (CHIP), as amended by the Affordable Care Act (ACA);

·      medical assistance for the elderly, blind, and disabled, through the Old Age Assistance (OAA), Aid to the Needy Blind (ANB), and Aid to the Permanently and Totally Disabled (APTD) Programs, currently found in the Adult Assistance Manual (AAM);

·      medical assistance for families and pregnant women of any age, currently found in the Family Assistance Manual (FAM);

·      Qualified Medicare Beneficiary (QMB), Qualified Disabled and Working Individuals (QDWI), and Specified Low Income Medicare Beneficiary (SLMB and SLMB135) programs, currently found in the AAM; and

·      long-term care (LTC) services through the Nursing Facility (NF), Home and Community-Based Care (HCBC), and HCBC Choices for Independence (CFI) Programs, currently found in the AAM and FAM.

 

POLICY

 

New Medical Assistance Manual (MAM) will, when completed, contain the official DFA policy governing the administration of all the medical assistance programs administered by DFA. The format of the MAM aligns with the other policy manuals offered by DFA:

 

·      Introduction

·      100 Case Processing

·      200 Program Criteria

·      300 Non-Financial Criteria

·      400 Resources

·      500 Income

·      600 Standards and Budgets

·      700 Miscellaneous

·      Glossary

 

Just as occurs with the other manuals, policy revisions will be issued by Supervisory Releases (SRs), which contain a narrative describing the changes. Replacement manual pages will be issued with the SR to internal DFA holders of the paper version of the manual. The electronic intra- and internet versions of the manual will be centrally updated through the Version Control process eleven times per year, as dictated by the state contract.

 

The header of each page within the MAM will identify:

 

·      the Chapter, Part, or Section number and title of the topic;

·      the manual affected (MAM);

·      the SR number which released the policy;

·      the effective date of the policy; and

·      for those with access to the Department’s computer network, an automated link to Previous Policy, if applicable.

 

Part numbers are three digits; the first digit identifies the Chapter (e.g., Part 409 is from Chapter 400). Section numbers further divide the Parts and use the Part number followed by a decimal point and two digits (e.g., 409.01 refers to Chapter 400, Part 409, Section 01).

 

As this manual is the basis for administering and implementing DFA medical assistance programs, it will be updated as policy is revised.

 

In this initial release that will be distributed at the end of October, the new MAM will contain:

 

·      any policies that currently apply to all medical assistance programs and/or that are not known to be changing with the impending implementation of Health Care Reform associated with the ACA; and

·      “placeholder” pages for policies anticipated to be changing for the implementation of Healthcare Reform. Text on these pages will reflect current policy and then contain a note at the end of the policy alerting the MAM user that the policy may be changing under the Affordable Care Act (ACA).

 

NEW HEIGHTS SYSTEMS PROCEDURES AND IMPLEMENTATION

 

During the generation of a Notice of Decision (NOD), New HEIGHTS “maps” the program action being taken, as described in the NOD, to the program policy that supports that action within each manual. Beginning October 1, 2013, New HEIGHTS has mapped certain ACA-related changes for the healthcare reform open enrollment period to the generic Chapters within the MAM. As these chapters are fleshed out, New HEIGHTS will update the mapping logic in the NODs so that the specific topics within the MAM that support the action described in the NOD will be fully displayed for clients.

 

POLICY MANUAL REVISIONS

 

Due to the large amount of pages that must be released for the new manual, only the following Chapters will be released in this SR: Introduction, Chapters 100, 200, and 700, and the Glossary. DFA SR 13-36 will release Chapters 300, 400, 500, and 600 under separate cover.

 

New Medical Assistance Manual Topics

 

Introduction

How To Use This Manual

How This Manual Is Updated

Navigating the Medical Assistance Manual

SR’s Retained

Chapter 100   CASE PROCESSING

PART 101   INDIVIDUAL RIGHTS AND RESPONSIBILITIES

Section 101.03  Individual Responsibilities

PART 103   NONDISCRIMINATION

Section 103.01  Racial and Ethnic Heritage Data

Section 103.03  Primary Language Data Collection

PART 105   COMPLIANCE WITH REQUIREMENTS

Section 105.01  Eligibility Determinations

Section 105.03  Eligibility Reviews

Section 105.05  Failure to Cooperate

Section 105.07  Willful Withholding of Information

PART 107   PROVIDING VERIFICATION

Section 109.05  Withdrawal of a Request for Assistance

Section 109.07  Reuse of Forms 800, 800HR, and 800MA After Denial or Closing

Section 109.09  Application for Retroactive Medical Assistance

Section 109.11  Choice of Medical Assistance

Section 109.13  Concurrent Receipt of Medical Assistance

PART 111   AUTHORIZED REPRESENTATIVES (AR)

Section 111.01  Authorized Representative (AR) Acting in Place of the Individual

Section 111.03  Authorized Representative (AR) Signature Required

Section 111.05  Authorized Representative (AR) Documentation Required

Section 111.07 Abuse by an Authorized Representative (AR) or Failure of an AR to Perform Their Duties

Section 121.01  Initiation of QMB, QDWI, SLMB, and SLMB135

PART 123   INTERVIEWS

Section 123.01  Interview Sites

Section 123.03  Failure to Appear for an Interview

PART 127   PENDING INFORMATION

PART 129   ELIGIBILITY DETERMINATIONS

Section 129.01  Presumptive Eligibility

PART 131   LENGTH OF ELIGIBILITY

PART 133   PROVIDING NOTICES TO INDIVIDUALS

PART 135   NOTICES OF DECISION (NOD)

PART 137   ADVANCE NOTICE PERIOD (ANP)

Section 137.03  No Advance Notice Period (ANP) Required

Section 137.05  Five-Day Advance Notice Period (ANP)

Section 137.07  30-Day Advance Notice Period (ANP)

PART 141    CHANGES

Section 141.01  Reporting Requirements

Section 141.03  What to Report

Section 141.05  How to Report

Section 141.07  When to Report

Section 141.09  Notifying Individuals of Reporting Requirements

PART 143   ACTIONS ON CHANGES

PART 145   CHANGES THAT INCREASE BENEFITS

PART 147   CHANGES THAT DECREASE BENEFITS

PART 151   ADDITION OF AN INDIVIDUAL

PART 153   FAILURE TO REPORT A CHANGE

PART 155   DESK REVIEWS

PART 157   REDETERMINATION

Section 157.01  Timely Notice

Section 157.03  Required Verification for Redeterminations

Section 157.05  Processing Redeterminations

Section 157.07  Redetermination of Assistance for Individuals Discharged from NH Hospital (NHH)

Section 157.09  Termination at Redetermination

PART 159   TERMINATION OF ASSISTANCE

Section 159.01  Termination of Medical Assistance

PART 161   EXTENDED MEDICAL ASSISTANCE DUE TO THE PICKLE AMENDMENT

Section 161.01  COLA Income Deduction

Section 161.03  COLA Adjustments Since 1977

Section 161.05  Losing Pickle Status

PART 163  EXTENDED MEDICAL ASSISTANCE DUE TO INCREASED CHILD OR SPOUSAL SUPPORT

Section 163.01  Determining the Four-Month Coverage Period

Section 163.03  Changes During the Four-Month Coverage Period

Section 163.05  Redetermination of Eligibility During the Four-Month Coverage Period

PART 165   EXTENDED MEDICAL ASSISTANCE DUE TO EMPLOYMENT

Section 165.01  Determining the Coverage Period

Section 165.03  Termination Due to Employment of an Incapacitated Parent

PART 167   ELIGIBILITY CRITERIA FOR 12-MONTH COVERAGE

Section 167.01  Definition of a Complete DFA Form 890

Section 167.03  Financial Eligibility

Section 167.05  Ineligibility Reasons

Section 167.07  Determining Good Cause

Section 167.09  Reinstatement After Termination

Section 167.11  Changes During the 12-Month Coverage Period

Section 167.13  Changes in Assistance Group Composition

Section 167.15  Scheduled Redeterminations of Eligibility

Section 167.17  Required Verification for 12-Month Coverage

PART 169   EXTENDED MEDICAL ASSISTANCE DUE TO SECTION 1619 STATUS

Section 169.01  Open Individuals Who Report New or Increased Earnings

Section 169.03  Individuals Who Request Assistance Due to Section 1619 Status

PART 171   TEMPORARY ADJUSTMENT PERIOD: APTD

PART 173   TEMPORARY ADJUSTMENT PERIOD: ANB

PART 175   MEDICAL ASSISTANCE FOR INMATES

Section 175.01  Inmates With an Approaching Release Date

Section 175.03   Inmates Who Become Inpatients in a Medical Facility While Incarcerated

Chapter 200   PROGRAM CRITERIA

PART 201   GENERAL INFORMATION

PART 203   CATEGORICAL REQUIREMENTS

PART 205   OLD AGE ASSISTANCE (OAA)

Section 205.01  Verification: OAA

PART 207   AID TO THE NEEDY BLIND (ANB)

Section 207.01  Verification: ANB

PART 209   AID TO THE PERMANENTLY AND TOTALLY DISABLED (APTD)

Section 209.01  Verification: APTD

Section 209.03  SGA Adjustments Since 2000

PART 211   MEDICAID FOR EMPLOYED ADULTS WITH DISABILITIES (MEAD)

Section 211.01  MEAD Medical Criteria

Section 211.03  MEAD Employment-Related Requirements

Section 211.05  MEAD Good Cause for Loss of Employment

Section 211.07  MEAD Income Requirements

Section 211.09  MEAD Resource Requirements and Treatments

Section 211.11  MEAD-Specific Resources

Section 211.13  MEAD Premium Requirements

Section 211.15  Good Cause for Non-Payment of MEAD Premiums

Section 211.17  Extensions of MEAD Coverage Due to Unemployment

Section 211.19  Termination of MEAD

PART 213   QUALIFIED MEDICARE BENEFICIARY (QMB)

Section 213.01  Verification: QMB

PART 215   QUALIFIED DISABLED AND WORKING INDIVIDUAL (QDWI)

Section 215.01  Verification: QDWI

PART 217  SPECIFIED LOW-INCOME MEDICARE BENEFICIARY AND SLMB135 (SLMB/SLMB135)

Section 217.01  Verification: SLMB and SLMB135

PART 219    FINANCIAL ASSISTANCE TO NEEDY FAMILIES (FANF)

Section 219.01  New Hampshire Employment Program (NHEP)

Section 219.03  Family Assistance Program (FAP)

Section 219.05  Families with Older Children (FWOC)

Section 219.07  Interim Disabled Parent (IDP)

Section 219.09  Unemployed Parent (UP)

PART 221    FANF-RELATED MEDICAL ASSISTANCE

Section 221.01  Children Up To Age 19

Section 221.03  Pregnant Women

Section 221.05  Severely Disabled Children

PART 223   CHILDREN’S MEDICAID

Section 223.01  Verification: CM

PART 225   PREGNANT WOMEN

Section 225.01  Continuation of Medical Assistance Following Pregnancy

Section 225.03   Required Verification

PART 227   FAMILY PLANNING MEDICAL ASSISTANCE (FPMA)

Section 227.01   Family Planning MA Eligibility Criteria

Section 227.03   Family Planning MA Application Process

Section 227.05   Family Planning MA Income Requirements

Section 227.07  Family Planning MA Resource Requirements

Section 227.09  Family Planning MA Allowable Deductions

Section 227.11  Family Planning MA Covered and Non-Covered Services

Section 227.13  Family Planning MA Retroactive Medical Assistance

Section 227.15  Family Planning MA In and Out Medical Assistance

Section 227.17   Family Planning MA Third Party Liability (TPL)

Section 227.19  Family Planning MA Length of Eligibility

Section 227.21  Family Planning MA Determining Presumptive Eligibility (PE)

Section 227.23  Family Planning MA Required Verification

PART 229   CHILDREN WITH SEVERE DISABILITIES (CSD)

Section 229.01  Required Verification: CSD

Section 229.03  Three-Month Temporary Adjustment Period

Section 229.05  CSD Children Turning 18 Years Old

PART 231   HOME CARE FOR CHILDREN WITH SEVERE DISABILITIES (HC-CSD)

Section 231.01  Medical Assistance Group Composition

Section 231.03  Required Verification: HC-CSD

Section 231.05  Three-Month Temporary Adjustment Period

Section 231.07  HC-CSD Children Turning 18 Years Old

PART 233   RESIDENTIAL CARE FACILITY

Section 233.01  Residential Care Facility Payment

Section 233.03  Verification: RCF

PART 235    COMMUNITY RESIDENCE

Section 235.01  Community Residence Payment

Section 235.03  Verification: Community Residence

PART 237   NURSING FACILITY

Section 237.01  Verification: Nursing Facility

PART 239   HOME AND COMMUNITY-BASED CARE CHOICES FOR INDEPENDENCE (HCBC-CFI)

Section 239.01  Verification: HCBC-CFI

PART 241   HOME AND COMMUNITY BASED CARE FOR IN-HOME SUPPORTS (HCBC-IHS)

Section 241.01  Verification: HCBC-IHS

PART 243  HOME AND COMMUNITY-BASED CARE FOR THE DEVELOPMENTALLY DISABLED (HCBC-DD)

Section 243.01  Verification: HCBC-DD

PART 245 HOME AND COMMUNITY-BASED CARE FOR INDIVIDUALS WITH AN ACQUIRED BRAIN DISORDER (HCBC-ABD)

Section 245.01  Verification: HCBC-ABD

PART 247   ASSISTANCE GROUP

Section 247.01  Disqualified Individuals

PART 249  ASSISTANCE GROUP COMPOSITION FOR OAA, ANB, OR APTD: INDEPENDENT LIVING

Section 249.01  Assistance Group Size for OAA, ANB, or APTD: Independent Living

PART 251   ASSISTANCE GROUP COMPOSITION FOR GROUP LIVING

PART 253   ASSISTANCE GROUP COMPOSITION FOR HCBC-DD/ABD/IHS

PART 255   ASSISTANCE GROUP COMPOSITION FOR HCBC-CFI

Section 255.01  HCBC-CFI Financial Assistance

Section 255.03  HCBC-CFI Medical Assistance

PART 257   ASSISTANCE GROUP COMPOSITION FOR QMB, QDWI, SLMB OR SLMB135

PART 259    COMPOSITION OF FANF MA ASSISTANCE GROUPS

Section 259.01  Who Must Be Members

Section 259.03  Who May Be Members

Section 259.05  Who Is Not A Member

PART 261   ASSISTANCE GROUP VERIFICATION

Chapter 700   MISCELLANEOUS

PART 707   ISSUING BENEFITS

Section 707.01  Issuing Medical Assistance Benefits

Section 707.03  Mailing Addresses

PART 713   MEDICAL ASSISTANCE FRAUD

Section 713.01  Medical Assistance Fraud

Section 713.03  Medical Assistance Fraud Penalties

Section 713.05  Court of Appropriate Jurisdiction for Medical Assistance Fraud

Section 713.07   Calculating the Amount of Repayment for Medical Assistance Fraud

Section 713.09   Recovering Overpayments Due to Medical Assistance Fraud: Collections

Section 713.11  Court Adjudicated Claims

Section 713.13  Medical Assistance Fraud at the Federal Level

Section 713.15  Federal Penalties for Medical Assistance Fraud

PART 715   BUY-IN OF MEDICARE

Section 715.01  Definition of Medicare

Section 715.03  Definition of Buy-In of Medicare Part A: QMB and QDWI

Section 715.05  Who Is Eligible for Medicare Part A Buy-In?

Section 715.07  When is Part A Buy-In Effective?

Section 715.09  How is Part A Buy-In Terminated?

Section 715.11  Medicare Part B Eligibility

Section 715.13  Definition of Buy-In of Medicare Part B

Section 715.15  Who is Eligible for Part B Buy-In?

Section 715.17  When is Part B Buy-In Effective?

Section 715.19  How Is Part B Buy-In Terminated?

Glossary   A-words

Glossary   B-words

Glossary   C-words

Glossary   D-words

Glossary   E-words

Glossary   F-words

Glossary   G-words

Glossary   H-words

Glossary   I-words

Glossary   L-words

Glossary   M-words

Glossary   N-words

Glossary   O-words

Glossary   P-words

Glossary   Q-words

Glossary   R-words

Glossary   S-words

Glossary   T-words

Glossary   U-words

Subsequent chapters will be released under separate cover.

 

IMPLEMENTATION

 

The bare bones of the new manual listing all MAM Chapters became available October 1, 2013. The manual sections described in this SR will be available following an upload scheduled for the evening of October 25, 2013.

 

CLIENT NOTIFICATION

 

No special client notification is planned.

 

TRAINING

 

No special training is planned.

 

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 28, 2013. Additionally, this SR, and printed pages with posting instructions, will be distributed under separate cover to all internal hard copy holders of the Medical Assistance Manual.

 

DFA/JBV:s