CHAPTER 21 ‑ MEDICAL ASSISTANCE ADMINISTRATION

 

SUBCHAPTER 21A ‑ GENERAL PROGRAM ADMINISTRATION

 

SECTION .0100 ‑ SUPERVISION

 

10A NCAC 21A .0101       SUPERVISION (TRANSFERRED TO 10A NCAC 23A .0101)

section .0200 – DEFINITIONS

 

10A NCAC 21A .0201       DEFINITIONS (TRANSFERRED TO 10A NCAC 23A .0102)

 

section .0300 - appeals

 

10A NCAC 21A .0301       NOTICE

In cases involving termination or modification of assistance, no action shall become effective until ten work days after the notice is mailed or delivered, except that it may be effective immediately when:

(1)           Modification is beneficial to the client; or

(2)           Federal regulations at 42 C.F.R. 431.213 are adopted by reference pursuant to G.S. 150B‑14(c).

 

History Note:        Authority G.S. 108A‑54; 108A‑79; 150B‑14(c); 42 C.F.R. 431.211; 42 C.F.R. 431.213;

Eff. September 1, 1984;

Amended Eff. August 1, 1990.

 

10A NCAC 21A .0302       GOOD CAUSE FOR DELAYED HEARINGS

(a)  A local appeal hearing shall be delayed for good cause as provided in G.S. 108A‑79(e).

(b)  A state appeal hearing may be delayed when there is good cause. The postponement may not exceed 30 calendar days.

(c)  Good cause exists when:

(1)           There is a death in the appellant's family;

(2)           The appellant or someone in his family is ill;

(3)           The appellant is unable to obtain representation;

(4)           The appellant's representative has a conflict with the scheduled date;

(5)           The appellant receives a notice of action proposing a reduction or termination of assistance after the ten work day notice expires;

(6)           The appellant is unable to obtain transportation;

(7)           The hearing officer determines that the hearing should be delayed for other circumstances satisfactory to the hearing officer.

 

History Note:        Authority G.S. 108A‑54; 108A‑79;

Eff. September 1, 1984;

Amended Eff. August 1, 1990.

 

10A NCAC 21A .0303       APPEAL DECISION

(a)  The hearing officer shall make a tentative decision which shall be served upon the county department and the appellant by mail.  Decisions proposing to reverse the county department's action shall be sent by certified mail to the county department while decisions affirming the county department's actions will be sent by certified mail to the appellant.

(b)  The county and the appellant may present oral and written argument, for and against the decision.  Written argument may be submitted to or contact made with the Chief Hearing officer to request a hearing for oral argument.

(c)  If the Chief Hearing Officer is not contacted within 10 calendar days of the date the notice of the tentative decision is signed, the tentative decision shall become final.

(d)  If the party that requested oral argument fails to appear at the hearing for oral argument, the tentative decision becomes final.

(e)  If oral and written arguments are presented, such arguments shall be considered and a final decision shall be rendered.

(f)  The final decision shall be mailed to the appellant any the county by certified mail.

(g)  A decision upholding the appellant shall be put into effect within two weeks after receipt of the final decision.

(h)  As provided for in 42 C.F.R. 431.245, the decision shall contain the appellant's right to request a State agency hearing and seek judicial review to the extent that either is available to him.

 

History Note:        Authority G.S. 108A‑54; 108A‑79; 42 C.F.R. 431.244; 42 C.F.R. 431.245; 42 C.F.R. 431.246;

Eff. September 1, 1984;

Amended Eff. September 1, 1992.

 

SECTION .0400 ‑ CONFIDENTIALITY AND ACCESS TO CLIENT RECORDS

 

10A NCAC 21A .0401       SCOPE (TRANSFERRED TO 10A NCAC 23H .0101)

 

10A NCAC 21A .0402       INFORMATION FROM OTHER AGENCIES (TRANSFERRED TO 10A NCAC 23H .0102)

 

10A NCAC 21A .0403       CONFIDENTIALITY (TRANSFERRED TO 10A NCAC 23H .0103)

 

10A NCAC 21A .0404       OWNERSHIP OF RECORDS (TRANSFERRED TO 10A NCAC 23H .0104)

 

10A NCAC 21A .0405       SECURITY OF RECORDS (TRANSFERRED TO 10A NCAC 23H .0105)

 

10a NCAC 21A .0406       LIABILITY OF PERSONS WITH ACCESS (TRANSFERRED TO 10A NCAC 23H .0106)

 

10A NCAC 21A .0407       RIGHT OF ACCESS (TRANSFERRED TO 10A NCAC 23H .0107)

 

10A NCAC 21A .0408       WITHHOLDING INFORMATION FROM THE CLIENT (TRANSFERRED TO 10A NCAC 23H .0108)

 

10A NCAC 21A .0409       PROCEDURE FOR REVIEW OF RECORDS (TRANSFERRED TO 10A NCAC 23H .0109)

 

10A NCAC 21A .0410       CONSENT FOR RELEASE (TRANSFERRED TO 10A NCAC 23H .0110)

 

10A NCAC 21A .0411       DISCLOSURE WITHOUT CLIENT CONSENT (TRANSFERRED TO 10A NCAC 23H .0111)

 

10A NCAC 21A .0412       DOCUMENTATION OF CONSENT OR DISCLOSURE (TRANSFERRED TO 10A NCAC 23H .0112)

 

10A NCAC 21A .0413       PERSONS DESIGNATED TO DISCLOSE INFORMATION (TRANSFERRED TO 10A NCAC 23H .0113)

 

SECTION .0500 ‑ QUALITY CONTROL

 

10A NCAC 21A .0501       QUALITY CONTROL (TRANSFERRED TO 10a NCAC 23A .0103)

 

SECTION .0600 ‑ CORRECTIVE ACTIONS IN MEDICAID CASES

 

10A NCAC 21A .0601       GENERAL (TRANSFERRED TO 10A NCAC 23G .0201)

 

10a NCAC 21A .0602       CORRECTIVE ACTIONS (TRANSFERRED TO 10A NCAC 23G .0202)

 

10A NCAC 21A .0603       TIME LIMITS FOR CORRECTIONS (TRANSFERRED TO 10A nCAC 23G .0203)

 

10A NCAC 21A .0604       RESPONSIBILITY FOR ERRORS (tRANSFERRED TO 10A nCAC 23G .0204)

 

10A NCAC 21A .0605       MONITORING THRESHOLDS AND CORRECTIVE ACTION (TRANSFERRED TO 10A NCAC 23C .0202)

 

10A NCAC 21A .0606       timeliness (TRANSFERRED TO 10A NCAC 23C .0203)

 

10A NCAC 21A .0607       local corrective action team (TRANSFERRED TO 10A NCAC 23C .0204)

 

10A NCAC 21A .0608       state corrective action team (TRANSFERRED TO 10A NCAC 23C .0205)

 

SECTION .0700 ‑ AVAILABILITY OF MANUALS

 

10A NCAC 21A .0701       AVAILABILITY OF MANUALS (TRANSFERRED TO 10A NCAC 23A .0104)

 

 

subchapter 21B – eligibility determination

 

SECTION .0100 – COVERAGE GROUPS

 

10A NCAC 21B .0101       MANDATORY (TRANSFERRED TO 10A nCAC 23D .0101)

10A ncac 21B .0102       OPTIONAL (TRANSFERRED TO 10A NCAC 23D .0102)

 

SECTION .0200 ‑ APPLICATION PROCESS

 

10A NCAC 21B .0201       ACCEPTANCE OF APPLICATION (TRANSFERRED TO 10A NCAC 23C .0101)

 

10A NCAC 21B .0202       face-to-face INTERVIEW (TRANSFERRED TO 10A NCAC 23C .0102)

 

10A NCAC 21B .0203       APPLICATION PROCESSING STANDARDS (TRANSFERRED TO 10A NCAC 23C .0201)

 

10A NCAC 21B .0204       EFFECTIVE DATE OF ASSISTANCE

(a)  The first month of Medicaid coverage shall be:

(1)           The month of application, or for SSI recipients, the month of application for SSI; or

(2)           As much as three months prior to the month of application when the client received medical services covered by the program and was eligible during the month or months of medical need; or

(3)           If the client applies prior to meeting a non‑financial requirement, no earlier than the calendar month in which all non‑financial requirements are met.

(b)  Assistance shall be authorized beginning on the first day of the month except when:

(1)           The client's income exceeds the income level and he must spenddown the excess income for medical care.  The assistance shall be authorized on the day his incurred medical care costs equal the amount of the excess income.

(2)           For groups identified in Rule .0311, Sub-item (3)(a) of this Subchapter, the client shall be authorized on the day the reserves are reduced, or incurred medical care costs equal the amount of the excess income, whichever occurs later.

(c)  Medicaid coverage shall end on the last day of the last month of eligibility except for those individuals eligible for emergency conditions only as described in 10A NCAC 23E .0102.  The last month of eligibility shall be:

(1)           The month in which timely notice of termination expires; or

(2)           The month in which adequate notice of termination expires.

 

History Note:        Authority G.S. 108A‑54; 42 C.F.R. 435.914; 42 C.F.R. 435.919; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. January 1, 1995; October 1, 1991; August 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004.

 

10A NCAC 21B .0205       RECOMMENDATION FOR DISPOSITION (TRANSFERRED TO 10A NCAC 23C .0103)

 

10A NCAC 21B .0206       DISPOSITION (TRANSFERRED TO 10A NCAC 23C .0104)

 

10A NCAC 21B .0207       REFERRALS at a face-to-face interview (TRANSFERRED TO 10A NCAC 23C .0105)

 

10A NCAC 21B .0208       MANDATORY USE OF OUTREACH LOCATIONS (TRANSFERRED TO 10A NCAC 23C .0106)

 

10A NCAC 21B .0209       hours for accepting financial and medical assistance applications (TRANSFERRED TO 10A ncac 23c .0107)

 

SECTION .0300 ‑ CONDITIONS FOR ELIGIBILITY

 

10A NCAC 21B .0301       AGE (TRANSFERRED TO 10A NCAC 23E .0101)

 

10A NCAC 21B .0302       UNITED STATES CITIZEN (TRANSFERRED TO 10A NCAC 23E .0102)

 

10A NCAC 21B .0303       RESIDENCE (TRANSFERRED TO 10A NCAC 23E .0103)

 

10A NCAC 21B .0304       DEPRIVATION (TRANSFERRED TO 10A NCAC 23E .0104)

 

10A NCAC 21B .0305       DISABILITY (TRANSFERRED TO 10A NCAC 23E .0105)

 

10A NCAC 21B .0306       BLINDNESS (TRANSFERRED TO 10A NCAC 23E .0106)

 

10A NCAC 21B .0307       CARETAKER RELATIVE (TRANSFERRED TO 10A nCAC 23E .0107)

 

10a NCAC 21B .0308       INMATE OF PUBLIC INSTITUTION OR PRIVATE PSYCHIATRIC HOSPITAL (TRANSFERRED TO 10A nCAC 23E .0108)

 

10A NCAC 21B .0309       APPLYING FOR ALL BENEFITS AND ANNUITIES (TRANSFERRED TO 10A NCAC 23E .0201)

 

10A NCAC 21B .0310       RESERVE (TRANSFERRED TO 10A NCAC 23E .0202)

 

10A NCAC 21B .0311       TRANSFER OF RESOURCES

In accordance with 42 U.S.C. 1396p(c), an individual who transfers resources and receives compensation that is less than the fair market value shall be ineligible to receive nursing facility services or in-home health services and supplies, as follows:

(1)           As provided for by P.L. 100‑360, Section 303(g) amended by P.L. 100‑485, Section 608(d)(16)(D), the provisions of 42 U.S.C. 1396p(c) shall be effective for all transfers of resources, including transfers of tenancy-in-common interest in real property, when requesting nursing facility services, for a level of care in a medical institution equivalent to that of a nursing facility services, or for home and community-based services, except transfers between spouses, occurring on or after July 1, 1988.  The provisions of 42 U.S.C. 1396p(c) shall be effective for transfers between spouses, occurring on or after October 1, 1989.

(2)           As allowed under 42 U.S.C. 1396p(c)(2)(D), the provisions of 42 U.S.C. 1396p(c) for ineligibility for nursing services due to transfer of resources shall not be applied:

(a)           To individuals who transferred resources after July 1, 1988 and before March 15, 1989 and were found eligible prior to March 15, 1989;

(b)           When it is determined by the agency's judgment that the applicant or recipient is a victim of fraud and did not take the action with the intent of becoming eligible for Medicaid.

(3)           In accordance with 42 USC 1396p(c), an Aged, Blind, or Disabled individual (42 CFR 435.120) or Qualified Medicare Beneficiary as described in (1905(p)(1) in a private living arrangement who transfers resources and receives compensation that is less than fair market value shall be ineligible to receive in-home health services and supplies (1905(a)(7) and 1905(a)(24) of the Social Security Act in accordance with this item.  These provisions do not apply to optional State Supplements (42 CFR 435.130).  The provisions of 42 USC 1396p(c) shall be effective for all transfers occurring on or after February 1, 2003.  As allowed under 42 USC 1396p(c), the provisions for ineligibility for these services due to transfer of resources shall not be applied;

(a)           to the individuals who referenced in this Paragraph transferred resources prior to February 1, 2003, and were found eligible either before or after February 1, 2003;

(b)           when it is determined by the agency's judgment that the applicant/recipient is a victim of fraud.

 

History Note:        Authority G.S. 108A‑54; 108A‑58; P.L. 100‑360; P.L. 100‑485; 42 U.S.C. 1396p(c); 42 C.F.R. 435.121; 42 C.F.R. 435.840; 42 C.F.R. 435.841; 42 C.F.R. 435.845; S.L. 2002-126;

Eff. September 1, 1984;

Amended Eff. December 1, 1991; August 1, 1990;

Temporary Amendment Eff. April 21, 2003; March 1, 2003;

Amended Eff. August 1, 2004.

 

10A NCAC 21B .0312       INCOME (TRANSFERRED TO 10A NCAC 23E .0203)

 

10A NCAC 21B .0313       PERSONAL NEEDS ALLOWANCE (TRANSFERRED TO 10A nCAC 23E .0204)

 

SECTION .0400 ‑ BUDGETING PRINCIPALS

 

10A NCAC 21B .0401       BUDGET UNIT MEMBERSHIP (TRANSFERRED TO 10A NCAC 23E .0205)

 

10A NCAC 21B .0402       FINANCIAL RESPONSIBILITY AND DEEMING (TRANSFERRED TO 10A NCAC 23E .0206)

 

10A NCAC 21B .0403       RESERVE (TRANSFERRED TO 10A NCAC 23E .0207)

 

10A NCAC 21B .0404       INCOME (TRANSFERRED TO 10A NCAC 23E .0208)

 

10A NCAC 21B .0405       CERTIFICATION AND AUTHORIZATION (TRANSFERRED TO 10A NCAC 23G .0101)

 

10A NCAC 21B .0406       DEDUCTIBLE (TRANSFERRED TO 10A NCAC 23E .0209)

 

10a NCAC 21B .0407       PATIENT LIABILITY (TRANSFERRED TO 10A NCAC 23E .0210)

 

10A NCAC 21B .0408       CLASSIFICATION (TRANSFERRED TO 10A NCAC 23D .0201)

 

10A NCAC 21B .0409       CHANGE IN SITUATION (TRANSFERRED TO 10A nCAC 23G .0304)

 

10A NCAC 21B .0410       ALIEN SPONSOR DEEMING (TRANSFERRED TO 10A NCAC 23E .0211)

 

SECTION .0500 ‑ REDETERMINATION

 

10A NCAC 21B .0501       TIME AND CONTENT (TRANSFERRED TO 10A NCAC 23G .0301)

 

10A NCAC 21B .0502       INTERVIEW (TRANSFERRED TO 10A NCAC 23G .0302)

 

10a NCAC 21B .0503       RECOMMENDATION (TRANSFERRED TO 10A NCAC 23G .0303)

 

 

 

SUBCHAPTER 21C ‑ BENEFITS

 

SECTION .0100 ‑ MEDICAID I.D. CARD

 

10A NCAC 21C .0101       MEDICAID IDENTIFICATION CARD (TRANSFERRED TO 10A NCAC 23B .0101)

10A NCAC 21C .0102       ISSUANCE (TRANSFERRED TO 10A NCAC 23B .0102)

 

10A NCAC 21C .0103       PHARMACY OF RECORD

 

History Note:        Authority G.S. 108A‑54;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Repealed Eff. April 1, 2010.

 

 

 

SUBCHAPTER 21D - ESTATE RECOVERY

 

SECTION .0100 - RECIPIENTS SUBJECT TO ESTATE RECOVERY

 

10A NCAC 21D .0101       NOTICE OF ESTATE RECOVERY

(a)  An individual who applies for Medicaid coverage for cost of care shall be given a written notice that a claim may be filed against their estate, if one exists, to recover Medicaid payments made on his behalf.

(b)  Notice shall be on a form prescribed by the Division of Medical Assistance and shall explain:

(1)           The types of Medicaid payments subject to estate recovery;

(2)           That recovery will not be claimed if the individual is survived by a legal spouse, child(ren) under age 21 or blind or disabled child(ren) of any age who became blind or disabled before age 21 and still live on the property of the individual;

(3)           That estate recovery is limited to recipients age 55 and over who receive certain Medicaid services or to recipients who are permanently institutionalized; and

(4)           That recovery may be waived in the case of undue hardship.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

10A NCAC 21D .0102       PERMANENTLY INSTITUTIONALIZED

(a)  Recovery shall apply to the estates of individuals under age 55 who seek Medicaid coverage for costs of care in a medical institution and who cannot reasonably be expected to be discharged to return home.

(b)  For purposes of estate recovery, medical institution means licensed nursing facilities, intermediate care for the mentally retarded facilities, nursing facility level of care in hospitals, or psychiatric inpatient care in a general hospital, psychiatric hospital, or mental institution. 

(c)  A determination that an individual cannot reasonably be expected to be discharged to return home is made when the individual seeks placement in or has been admitted to a medical institution using the following evidence:

(1)           Admission forms for level of care, physician written statement of discharge plans, or plans of care which indicate care needs are not of temporary duration, or

(2)           Individual continues to be a resident of a medical institution at the end of a temporary stay predicted by his physician at the time of admission to be no longer than six months in duration.

(d)  Notice of the determination that the individual is residing in a medical institution cannot reasonably be expected to be discharged to return home shall be given to the individual, or to his parent/guardian/responsible person if the individual is incompetent, within three work days after the determination.  The notice shall explain the right to request a reconsideration review, and the time limits and procedures for doing so.

(e)  The individual or his parent/guardian/responsible person may request a reconsideration review of the determination under Section .0200 of this Subchapter.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

10A NCAC 21D .0103       AGE 55 AND OVER

(a)  Recovery shall apply to the estates of individuals who on or after reaching age 55 receive Medicaid coverage for nursing facility level of care or under a home and community based alternative program for individuals who would otherwise qualify for nursing facility level of care.

(b)  Written notice that the state may file a claim against their estate to recover the payments made by the Medicaid Program on their behalf shall be given to individuals at the time of approval of eligibility for nursing facility level of care or approval for home and community based alternatives services.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

SECTION .0200 - RECONSIDERATION REVIEW

 

10A NCAC 21D .0201       RECONSIDERATION REVIEW

(a)  The recipient or his parent/guardian/responsible person acting on behalf of the recipient may request reconsideration of the determination that the individual cannot reasonably be expected to be discharged to return home based on relevant evidence stated in Rule .0101 of this Subchapter.

(b)  A reconsideration review shall be requested in writing to the Division of Medical Assistance estate recovery administrator within 30 calendar days of the determination and written notice provided by the county department of social services.

(c)  Within 30 calendar days of a written request for reconsideration of the determination of permanent institutionalization, the estate recovery administrator shall establish a reconsideration date and conduct a review of:

(1)           All evidence considered by the county department of social services in making a determination of permanent institutionalization, and

(2)           Information provided in writing or by telephone conference with the recipient or an individual acting on behalf of the recipient.

(d)  The review shall be conducted in the Division of Medical Assistance offices and may include a telephone conference with the recipient or an individual acting on behalf of the recipient if oral testimony is requested.

(e)  A decision shall be made and provided in writing to the recipient or an individual acting on behalf of the recipient within 15 calendar days of the date of the reconsideration review.

(f)  If the recipient disagrees with the decision of the reconsideration review, he may appeal to the Office of Administrative Hearings (OAH) within 60 calendar days of receipt of the reconsideration review decision.  If no appeal to OAH is filed, the reconsideration review decision is final.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

SECTION .0300 - MEDICAID PAYMENTS SUBJECT TO RECOVERY

 

10A NCAC 21D .0301       PERMANENTLY INSTITUTIONALIZED

(a)  For permanently institutionalized individuals recovery shall be claimed for all Medicaid payments, including cost sharing charges for Medicare services and Medicare premiums, made on behalf of individuals for the period of time the individual received care in a medical institution, including the period of time prior to the date the recipient is determined permanently institutionalized whether or not such periods were consecutive.  The amount of recovery shall be limited to the amount of Medicaid payments for services and benefits described herein.

(b)  No recovery shall be claimed for any period of time the recipient was discharged from a medical institution and lived in the community for a period of 30 or more consecutive days.

(c)  No recovery shall be claimed if the recipient is survived by one or more of the relatives listed in Section .0100 of this Subchapter.

(d)  No recovery shall be claimed if the Division of Medical Assistance determines under provisions of Section .0500 of this Subchapter that it is not cost effective or if recovery would create undue hardship to a survivor.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

10A NCAC 21D .0302       AGE 55 AND OVER

(a)  For individuals age 55 and over recovery shall be claimed for Medicaid payments for the following services and benefits:

(1)           Nursing facility level of care;

(2)           Home and community based alternatives services;

(3)           Related hospital care received during approved care under either Subparagraph (1) or (2) of this Paragraph;

(4)           Prescription drugs received during approved care under either Subparagraph (1) or (2) of this Paragraph; and

(5)           Medicare premiums paid during the time of approved care under either Subparagraph (1) or (2) of this Paragraph.

(b)  The amount of recovery shall be limited to the amount of Medicaid payments and benefits described in Paragraph (a)(1)-(5) of this Rule.

(c)  No recovery shall be claimed if the recipient is survived by one or more relatives listed in Section .0100 of this Subchapter.

(d)  No recovery shall be claimed if the Division of Medical Assistance determines under provisions of Section .0500 of this Subchapter that it is not cost effective or if recovery would create undue hardship to a survivor.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

SECTION .0400 - FILING AND COLLECTION OF CLAIMS AGAINST ESTATE

 

10A NCAC 21D .0401       FILING CLAIM AGAINST ESTATE

(a)  Within 60 days after the date of a recipient's death, the Division of Medical Assistance or its fiscal agent shall produce a claim document summarizing all Medicaid payments subject to recovery as stated in Rules .0301 and .0302 of this Subchapter.

(b)  The claim shall be mailed to the county department of social services from which the individual received Medicaid.

(c)  Following a determination that the recipient is not survived by any of the relatives listed in Section .0100 of this Subchapter, the county department of social services shall file the claim by certified mail with the individual who has been named to administer the estate and shall send a copy to the clerk of court for his records.  At the time the claim is filed the administrator shall be notified that recovery will be waived if the assets in the estate are below five thousand dollars ($5,000), and of the procedures for requesting a determination of undue hardship.

(d)  The claim shall be filed regardless of whether an appeal or determination of permanent institutionalization status has been decided.

(e)  If an administrator of the decedent's estate has not been appointed at the time the claim is received in the county, within 30 calendar days the county shall request the name of the administrator from the clerk of court and shall file the claim directly with the clerk of court if no appointment has been made.

(f)  At any time that the county department of social services determines that the decedent is survived by any of the relatives listed in Section .0100 of this Chapter or that the decedent does not have an estate, it shall notify the Division of Medical Assistance to cease recovery efforts.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

10A NCAC 21D .0402       COLLECTION OF CLAIMS

(a)  Estate for purposes of recovery of Medicaid payments is defined under G.S. 28A-15-1.

(b)  Unless the Division of Medical Assistance waives or reduces its claim, recovery under rules in Section .0500 of this Subchapter, recovery shall be claimed in full for the amount of the Medicaid claim to the extent that assets in the estate are sufficient to meet the state's claim as a fifth class creditor.

(c)  All recoveries for Medicaid claims shall be remitted to the Division of Medical Assistance by the administrator of the decedent's estate, any individual or entity designated by the clerk of court or by the clerk of court.

(d)  Amounts recovered shall be shared by the federal, state and county governments in proportion to the financial share of program costs borne by each at the time recovery is received.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

SECTION .0500 - WAIVER OF RECOVERY

 

10A NCAC 21D .0501       RECOVERY NOT COST EFFECTIVE

Recovery shall be deemed to not be cost effective and shall be waived when:

(1)           The amount of Medicaid payments for services and benefits subject to recovery is less than three thousand dollars ($3,000), or

(2)           The assets in the estate are below five thousand dollars ($5,000).

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

10A NCAC 21D .0502       UNDUE HARDSHIP

(a)  Recovery shall be waived if enforcement of the claim will cause undue or substantial hardship to the surviving heirs of the decedent.

(b)  Undue or substantial hardship shall include the following:

(1)           Real or personal property included in the estate is the sole source of income for a survivor and the net income derived is below 75 percent of the federal poverty level for the dependents of the survivor(s) claiming hardship, or

(2)           Recovery would result in forced sale of the residence of a survivor who lived in the residence for at least 12 months immediately prior to and on the date of the decedent's death and who would be unable to obtain an alternate residence because the net income available to the survivor and his spouse is below 75 percent of the federal poverty level and assets in which the survivor or his spouse have an interest are valued below twelve thousand dollars ($12,000).

(c)  Undue hardship shall not include loss of a pre-existing standard of living nor the establishment of a source of maintenance that did not exist prior to the decedent's death.

(d)  A claim of undue hardship to a survivor shall be made in writing to the Division of Medical Assistance estate recovery administrator within 30 days after the surviving heir claiming undue hardship has been notified of the Medicaid claim.  The claim of hardship shall describe the financial circumstances of the heir and the basis for his dependence on assets in the decedent's estate.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.

 

10A NCAC 21D .0503       DETERMINATION OF UNDUE HARDSHIP

(a)  The estate recovery administrator shall evaluate each claim of hardship within 60 calendar days of the request to make a determination to waive recovery of the claim in part or in full.  In making this determination, the administrator may request documentation to support the survivor's claim of hardship including prior year's income tax returns, bank statements, wage and earnings files, real and personal property records, utility records, tax records, medical bills, or other documents offered by the survivor to support his claim.

(b)  If documentation necessary to evaluate the claim of hardship is not provided or the survivor requests additional time to obtain the documentation, the administrator may extend the review for an additional 30 days.

(c)  The claim of hardship shall be denied if the necessary documentation is not provided within the time frames stated in Paragraphs (a) and (b) of this Rule.

(d)  The administrator shall notify in writing the survivor claiming hardship, the administrator and the clerk of court of his decision within 10 calendar days after completing the review of the request and documentation supporting the claim of hardship.  The notice shall explain the right to appeal to the Office of Administrative Hearings (OAH) and the time limit and procedure for doing so.

(e)  If the survivor disagrees with the decision, he may appeal to the Office of Administrative Hearings (OAH) within 60 calendar days of receipt of the decision.  If no appeal to OAH is filed, the decision shall be final.

 

History Note:        Authority G.S. 108A-70.5; 42 U.S.C. 1396p.;

Temporary Adoption Eff. May 6, 1996 to expire on July 1, 1996, or the last day of the 1996 session of the General Assembly, whichever is later;

Temporary Rule Expired on July 1, 1996;

Eff. July 1, 1996.