CHAPTER 23 - MEDICAL ASSISTANCE ADMINISTRATION

 

SUBCHAPTER 23A - GENERAL PROGRAM ADMINISTRATION

 

SECTION .0100 - GENERAL

 

10A NCAC 23A .0101       SUPERVISION

 

History Note:        Authority G.S. 108A-25(b); 108A-54;

Eff. September 1, 1984;

Amended Eff. August 1, 1990; January 1, 1986;

Transferred from 10A NCAC 21A .0101 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

10A NCAC 23A .0102       DEFINITIONS

For purposes of this Chapter, the following definitions apply:

(1)           "M-AA" means a program of medical assistance to persons 65 years of age and older, and also means the assistance itself.

(2)           "M-AB" means a program of medical assistance to blind persons, and also means the assistance itself.

(3)           "M-AD" means a program of medical assistance to disabled persons less than 65 years of age, and also means the assistance itself.

(4)           "M-AF" means a program of medical assistance for families and children, and also means the assistance itself.

(5)           "M-IC" means a program of medical assistance for infants and children, and also means the assistance itself.

(6)           "M-PW" means a program of medical assistance for pregnant women, and also means the assistance itself.

(7)           "M-QB" means a program of medical assistance for qualified medicare beneficiaries described at 42 U.S.C. 1396d(p), and also means the assistance itself.

(8)           "AFDC" means a program of assistance for families with dependent children, and also means the assistance itself.

(9)           "AFDC-MA" has the same meaning as "M-AF".

(10)         "Adequate Notice" means a written notice to inform the client of intended action.  The client must receive this notice no later than the effective date of the action.

(11)         "Advance Notice" means a written notice to inform the client at least 10 work days prior to terminating assistance, beginning or increasing a deductible, or beginning or increasing patient monthly liability.

(12)         "Agency" means the Division of Medical Assistance and the county departments of social services, unless separately identified.

(13)         "Appeal" means an oral or written request from a client for a hearing to review the action of a county department of social services or the disability decision when the client is dissatisfied with the decision in his case.

(14)         "Application" means a written request for assistance on a form prescribed by the state that is signed under penalty of perjury by a client or an individual authorized by the client to be his representative for establishing his eligibility for medical assistance.

(15)         "Authorization Period" means the period for which all conditions of eligibility have been established and for which the client is authorized to receive a Medicaid card and benefits.

(16)         "Award Letter" means a statement to an individual from a governmental or private agency indicating benefits for which he is eligible.

(17)         "BENDEX" means Beneficiary Data Exchange with the Social Security Administration for social security status and amount of benefits.

(18)         "Budget Unit" means all persons whose income and needs are considered in the determination of eligibility for Medicaid.

(19)         "Caretaker Relative" means a parent or a person in one of the following groups with whom a child lives:

(a)           any blood relative, including those of half-blood, and including first cousins, nephews, or nieces, and persons of preceding generations as denoted by prefixes of grand, great, or great-great;

(b)           stepfather, stepmother, stepbrother, and stepsister;

(c)           persons who legally adopt a child, their parents as well as the natural and other legally adopted children of such persons, and other relatives of the adoptive parents in accordance with state law;

(d)           spouses of any persons named in the groups in Subitem (19)(a) - (c) of this Rule even after the marriage is terminated by death or divorce.

(20)         "Certification Period" means the months for which eligibility is being established.

(21)         "Client" means any applicant for or recipient of Medicaid, or someone who makes inquiries, is interviewed, or has been otherwise served or someone acting for the client.

(22)         "Client Information" or "Client Record" means any information, including information stored in computer data banks or computer files relating to a client that was received in connection with the performance of any function of the agency.

(23)         "Collateral" means a person or agency who can substantiate or verify information necessary to establish eligibility.

(24)         "Contiguous Property" means real property with boundaries joining the homesite of the client.

(25)         "Court Order" means any written order from a judge or a written document from a judicial official that explicitly directs the release of client information.

(26)         "Deductible" means the amount that the client or budget unit member must personally spend or incur for medical expenses before he can be authorized to receive a Medicaid card and services that may be billed to the Medicaid program.

(27)         "Delegated Representative" means a staff member designated by the director to carry out the responsibilities established by the rules in this Subchapter.  Designation is implied when the assigned duties of an employee require access to confidential information.

(28)         "Deprivation" means the lack of support or care from one or both parents (including adoptive parents) of a dependent child, as a result of the absence, incapacity, unemployment, or death of either parent.

(29)         "Director" means the head of the Division of Medical Assistance or the county department of social services.

(30)         "Disregard of Earned Income" means the procedure for exempting portions of earned income as a resource when determining the amount of payment.

(31)         "Documentary Evidence" means information or records that can be relied on to prove the client's statements of fact.

(32)         "Effective Date" means the date on which an action will take effect.

(33)         "Equity" means the tax value of a resource less the amount of debts, liens, or other encumbrances.

(34)         "Excluded Income" means money received by a member of the budget unit that is not counted in determining eligibility for assistance.

(35)         "Foster Care Resource" means any private home or facility licensed to provide full time care to children.

(36)         "Fraud" means an act in which a client makes false statements or withholds information willfully and knowingly with the intent to deceive, or both, and as a result obtains assistance for which he is not eligible.

(37)         "Full-Time Student" means a student so designated by the school in which he is enrolled.

(38)         "Good Cause" includes death, incapacity, hospitalization of the applicant/recipient (a/r), failure to receive written notice, or failure of a representative acting on the a/r's behalf to meet required time frames.

(39)         "Grandfathered Status" means Medicaid eligibility based on the individual's status as a blind or disabled client or as an essential spouse of aged, blind, or disabled client in December, 1973.

(40)         "Greater Weight of Evidence" means evidence of such quality as to persuade an ordinary and prudent person of the truth or falsity of a statement.

(41)         "Guardian" means an individual, corporation, or disinterested public agent appointed by the clerk of superior court to replace an individual's authority to make decisions about his person, family, or property when the individual does not have adequate capacity to make such decisions and has been adjudicated incompetent.  A guardian may be a guardian of the person, a guardian of the estate, or a general guardian which is guardian of both the person and the estate.

(42)         "HCT (Healthy Children and Teens)" means a program which provides health screenings and treatment for clients from birth through age 20.

(43)         "Incapacity" has the same meaning as in the North Carolina State plan approved under Part A of Title IV of the Social Security Act as in effect on July 16, 1996, as is required by 42 U.S.C. 1396u-1.

(44)         "Income" means money that is available to members of the budget unit for their needs.

(45)         "Income, Earned" means money received as a result of employment.

(46)         "Income, Gross" means total income before allowable deductions.

(47)         "Income, Net" means income after all allowable deductions.

(48)         "Income, Unearned" means money received from any source other than employment.

(49)         "Incompetent Adult" means an adult who lacks sufficient capacity to manage his own affairs or to make or communicate decisions concerning his person, family, or property whether such lack of capacity is due to mental illness, mental retardation, epilepsy, cerebral palsy, autism, senility, disease, injury, or similar cause or condition.

(50)         "Inmate of a Public Institution" means a person who lives in an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control and that provides treatment or services, food and shelter.

(51)         "Institutionalized Spouse" means an individual who:

(a)           is in a medical institution or nursing facility or who is described under 42 U.S.C. 1396a (a) (10) (A) (ii) (VI); and

(b)           is married to an individual who is not in a medical institution or nursing facility;

but does not include any such individual who is not likely to meet the requirements of Subitem (51)(a) for at least 30 consecutive days.

(52)         "Life Estate Interest" means the right to use property and receive income from the property for the remainder of one's life.

(53)         "Long Term Care" means care in:

(a)           a general or specialty hospital in excess of 30 continuous days;

(b)           a state mental hospital;

(c)           a skilled nursing facility; or

(d)           an intermediate care facility.

(54)         "Patient Monthly Liability" means the amount of a long term care patient's income that must be paid towards his cost of care.

(55)         "Remainder Interest" means ownership interest in property that will be inherited in full or jointly with other remainder interest holders at a life interest holder's death.

(56)         "Representative" means a person who is authorized by the client to act on behalf of the client.

(57)         "Reserve" means assets owned by members of the budget unit and that have a market value.

(58)         "Residence" means the county where a client lives with intent to remain for an indefinite time as governed by 10A NCAC 23E .0103.  Also, an individual under age 21 has the residence of the person with whom he resides unless he is in the custody of a social services agency, in which case he is a resident of the county of the custodial agency.

(59)         "Revocable Trust" means funds held in trust that are available for the client's use.

(60)         "RSDI (Retirement, Survivors, Disability Insurance)" means social security benefits.

(61)         "SDX" means State Data Exchange with the Social Security Administration for the purpose of providing a listing of all persons receiving supplemental security income, their current payment status and amount of SSI and other sources of income.

(62)         "SSI" means Supplemental Security Income, a federal assistance payment for aged, blind and disabled persons administered by the Social Security Administration.

(63)         "Stepparent" means that a person is not the parent of a child but the person is married to the parent of the child who wants to receive Medicaid.

(64)         "Timely Notice" means the same as "Advance Notice".

(65)         "Time Standard" means the requirement to process an application within 45 or 90 days from the date of application in accordance with 42 C.F.R. 435.911.

(66)         "Verification" means the confirmation of facts and information used in determining eligibility.

 

History Note:        Authority G.S. 108A-25(b); 108A-54; P.L. 99-509; P.L. 100-360; P.L. 100-485; 42 C.F.R. 431.211; 42 C.F.R. 431.214; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0201 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23A .0103       QUALITY ASSURANCE

(a)  Case actions taken by the county department of social services are subject to review by state and federal quality control procedures.  A statistical sample is selected from both active and negative case actions.

(b)  The purpose of the QC review is to identify eligibility errors and erroneous payments resulting from:

(1)           Ineligibility;

(2)           Recipient liability understated or overstated;

(3)           Third-party liability; and

(4)           Claims processing errors.

(c)  A report of an error discovered in a QC case shall be sent to the appropriate county agency for corrective action.

(d)  If the county agency has verification that disputes a QC finding of error, it may submit the verification to the Recipient Services Section for review.  The Recipient Services Section cannot overturn a listed error, but shall determine whether the error shall be coded client-responsible, agency-responsible, or state-responsible.  Upon its review, the Recipient Services Section shall notify the county agency of its decision regarding responsibility for the error.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 431.800;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0501 Eff. May 1, 2012.

 

10A NCAC 23A .0104       AVAILABILITY OF MANUALS

(a)  One copy of the Medicaid Eligibility Manual and other policy issuances affecting the public is maintained in each county department of social services and each DSS Regional Office for examination by the public on regular work days during regular work hours.

(b)  The state provides copies of its current eligibility policy free of charge to agencies and organizations described in 42 CFR 431.18.

(c)  The state will charge agencies and groups other than those covered by Paragraph (b) of this Rule an amount related to the cost of reproduction.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 431.18;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0701 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

 

SUBCHAPTER 23B ‑ BENEFITS

 

SECTION .0100 ‑ GENERAL

 

10A NCAC 23B .0101       MEDICAID IDENTIFICATION CARD

The card shall be proof to medical providers of the client's Medicaid eligibility for a specified time.

 

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

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21C .0101 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10A NCAC 23B .0102       ISSUANCE

(a)  Cards shall be issued by the state at any time of the month for:

(1)           Approved applications;

(2)           Cases authorized after meeting a deductible; or

(3)           Requests by the county agency.

(b)  Cards shall be issued by the state at the beginning of each month for clients authorized for the month.

(c)  Cards shall be issued by the county agency for:

(1)           Emergencies as indicated in the Eligibility Manuals;

(2)           Replacement of lost, stolen, burned or incorrect cards;

(3)           Non-receipt of a state issued card; and

(4)           Requests by a second county during a county transfer.

 

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

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21C .0102 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

 

 

subchapter 23c – application for medicaid benefits

 

SECTION .0100 ‑ APPLICATION PROCESS

 

10A NCAC 23c .0101       ACCEPTANCE OF APPLICATION

(a)  A client shall be allowed to apply without delay.  Without delay is the same day the client appears at the county department of social services expressing a financial or medical need.

(b)  The county department of social services shall not act to discourage any individual from applying for Medicaid.  It shall be considered discouragement if any employee of the county department of social services:

(1)           requires or suggests the individual wait to apply until he applies for other benefits or until an application for other benefits has been approved or denied; or

(2)           incorrectly states or suggests the individual is ineligible for Medicaid; or

(3)           gives incorrect or incomplete information about Medicaid programs; or

(4)           requires the individual provide or obtain any information needed to establish eligibility prior to signing an application; or

(5)           discourages a client from applying and this is proven by facts to the satisfaction of the county agency or a hearing officer; or

(6)           suggests that the individual make an appointment to apply when he appears at the agency; or

(7)           suggests that the individual complete a mail-in application when he appears at the agency; or

(8)           fails to explain the date of application when he appears at the agency and requests a mail-in application; or

(9)           fails to explain and offer Medicaid to individuals requesting Work First Employment Services.

(c)  The client shall be informed verbally and in writing, that:

(1)           he can apply without delay;

(2)           a decision shall be made concerning his eligibility within 45 calendar days from the date of application for Medicaid, except for M-AD.  For M-AD the application processing standard shall be 90 calendar days from the date of application; and

(3)           he shall receive a written decision concerning his eligibility.

(d)  The client shall apply in his county of residence.

(e)  The date of the application shall be:

(1)           The date the client or his representative signs the state application form for Medicaid, including Work First, under penalty of perjury at the county department of social services; or

(2)           The date a signed complete state mail-in application form is received by the county department of social services in the county of residence.  Complete is defined as information that is legible, signed, submitted to correct county of residence, and has identifying information for the person applying, including name, mailing address, date of birth and gender.

(f)  If an individual requests assistance by mail, the letter shall be considered a request for information.  Within three workdays following receipt of the request, the county agency shall mail follow-up information to the individual.  The county agency shall advise the individual to come to the agency to apply and be interviewed, or if he is unable to come in person, to contact the agency so other arrangements can be made to take his application.

(g)  If an individual requests assistance by telephone, he shall be advised to come to the county agency to sign an application and be interviewed; or, if he is unable to come to the agency in person other arrangements shall be made to take his application.

(h)  If an individual sends in a complete state mail-in application form, the county department of social services shall use this application to determine eligibility for Medicaid.  A mail-in application form may be picked up at a local county department of social services or other locations as determined by the State and county.

(i)  An individual or his representative must request a determination for retroactive SSI Medicaid no later than 60 days from the date of the SSI Medicaid disposition notice or 90 days if good cause is established.  Good cause exists when:

(1)           the applicant does not receive the SSI Medicaid notice;

(2)           the applicant or his representative dies;

(3)           the applicant is incapacitated, incompetent, or unconscious and there is no representative acting on his behalf;

(4)           the applicant or spouse, child, parent, or representative of applicant is hospitalized for an extended period of time; or

(5)           the applicant's representative fails to meet the required time frame.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.906; 42 C.F.R. 435.907; 42 C.F.R. 435.911; Alexander v. Flaherty, U.S.D.C., W.D.N.C., File No. C-C-74-183, Consent Order filed 15 December 1989; Alexander v. Flaherty Consent Order filed February 14, 1992; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. January 1, 1995; April 1, 1993; August 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0201 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10A NCAC 23c .0102       face-to-face INTERVIEW

(a)  The county department of social services shall conduct a face-to-face interview with the client or his representative who appears at the agency requesting financial or medical assistance.  The client may have any person or persons of his choice participate in the interview.  During the interview, the Income Maintenance Caseworker shall explain the application process, the client's rights and responsibilities, the programs of public assistance and the eligibility conditions.

(b)  The applicant shall be advised of his right to apply in more than one program category for which he qualifies and the advantages and disadvantages of the choices shall be explained.

(c)  The client shall be informed of the following:

(1)           The client shall be told what information that he is required to provide, and what third party sources the agency shall contact to check the information.  Third party sources are entities, other than the client, that can provide verification of information to determine eligibility.

(2)           The client has the right to:

(A)          Receive assistance if found eligible;

(B)          Be protected against discrimination on the grounds of race, creed, or national origin by Title VI of the Civil Rights Act of 1964.  He may appeal such discrimination;

(C)          Have any information given to the agency kept in confidence;

(D)          Appeal, if he believes the agency's action to deny, change, or terminate assistance is incorrect, or his request is not acted on with reasonable promptness;

(E)           Reapply at any time, if found ineligible;

(F)           Withdraw from the program at any time;

(G)          Request the agency's help in obtaining third party information that he is responsible to provide;

(H)          Be informed of all information he must provide and all alternative sources for obtaining the information.

(3)           The client shall:

(A)          Provide the county department, state and federal officials, the necessary sources from which to locate and obtain information needed to determine eligibility;

(B)          Report to the county department of social services any change in situation that may affect eligibility within 10 calendar days after it happens.  The Income Maintenance Caseworker shall explain the meaning of fraud and shall inform the applicant that he may be suspected of fraud if he fails to report a change in situation and that in such situations, he may have to repay assistance received in error and that he may also be tried by the courts for fraud;

(C)          Inform the county department of social services of any persons or organization against whom he has a right to recover medical expenses.  When he accepts medical assistance, the applicant shall assign his rights to third party insurance benefits to the state.  The Income Maintenance Caseworker shall inform the applicant that it is a misdemeanor to fail to disclose the identity of any person or organization against whom he has a right to recover medical expenses;

(D)          Immediately report to the county department the receipt of an I.D. card that he knows to be erroneous.  If he does not report such and uses the I.D. card, he shall repay any medical expenses paid in error.

 

History Note:        Authority G.S. 108A-25(b); 108A-57; 42 C.F.R. 435.908; Alexander v. Flaherty, U.S.D.C., W.D.N.C., File No. C-C-74-183, Consent Order Filed 15 December 1989; Alexander v. Flaherty Consent Order filed February 14, 1992; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990; March 1, 1986;

Temporary Amendment Eff. August 22, 1996;

Amended Eff. August 1, 1998;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0202 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0103       RECOMMENDATION FOR DISPOSITION

(a)  When all information necessary to determine eligibility has been obtained, the Income Maintenance Caseworker shall recommend whether to approve or to deny assistance.  The recommendation shall be based on all reliable, relevant information.

(b)  The authority to approve or deny assistance rests with the county board of social services.  The county board may, by appropriate resolution recorded in the board minutes, delegate to the county director of social services the authority to process applications, to determine eligibility, or to terminate assistance.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.913;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0205 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23c .0104       DISPOSITION

(a)  Disposition of the application shall complete the application process and shall consist of one of the following actions:

(1)           Approval of assistance;

(2)           Denial of assistance;

(3)           Denial of assistance for ineligible month or months of the certification period and approval for eligible month or months of the certification period; or

(4)           Voluntary withdrawal of the application by the client.  The Income Maintenance Caseworker shall not suggest to the client that he withdraw his application and shall explain alternatives to withdrawal.  The Income Maintenance Caseworker shall explain the client's right to reapply at anytime.

(b)  The county department of social services shall not deny an application prior to 45 days, or for M-AD, 90 days, except when:

(1)           It is established the applicant will not be able to meet the deductible;

(2)           The applicant cannot be located; or

(3)           The applicant refuses to cooperate or provide information to establish eligibility;

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.912; 42 C.F.R. 435.913; Alexander v. Flaherty, U.S.D.C., W.D.N.C., File No. C-C-74-183, Consent Order filed 15 December 1989; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0206 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0105       REFERRALS at a face-to-face interview

For all Medicaid applicants who have a face-to-face interview at the county department of social services, the Income Maintenance Caseworker shall explain and make referrals for:

(1)           Health Check;

(2)           Family planning services;

(3)           Food stamps;

(4)           Governmental benefits including RSDI, SSI, VA;

(5)           Women, Infants and Children Program (WIC);

(6)           Carolina ACCESS;

(7)           Medicaid Transportation;

(8)           Life Line/Link-up;

(9)           Health Insurance Premium Payment program; and

(10)         Voter Registration.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 441.56; 42 U.S.C. 1396a(a); Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

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

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0207 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0106       MANDATORY USE OF OUTREACH LOCATIONS

The county department of social services shall provide for the acceptance of applications and initial interviews for M-PW and M-IC coverage groups at certain outreach locations as follows:

(1)           disproportionate share acute care hospitals which serve the coverage groups listed; and

(2)           Medicaid enrolled federally qualified health centers.

 

History Note:        Authority G.S. 108A-43; 108A-54; P.L. 101-508;

Temporary Adoption Eff. July 1, 1991, for a period of 180 days to expire

Eff. January 1, 1992;

Transferred from 10A NCAC 21B .0208 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0107       hours for accepting financial and medical assistance applications

The county department of social services must maintain the same number of operating hours as in February of 2002. Provisions must be made for acceptance of financial and medical assistance applications if the agency elects to close for lunch or for other reasons during the week.

 

History Note:        Authority G.S. 108A-54; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Temporary Adoption Eff. March 1, 2003;

Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0209 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

section .0200 – application processing, monitoring and corrective action

 

10A NCAC 23C .0201       APPLICATION PROCESSING STANDARDS

(a)  The county department of social services shall comply with the following standards in processing applications:

(1)           A decision on an individual's eligibility for Medicaid shall be made within 45 calendar days from the date of application for Medicaid except for applications in which a disability determination has already been made or is needed.  For those applications, a decision on an individual's eligibility shall be made within 90 days from the date of application.  These timeframes shall apply in accordance with 42 CFR 435.911.

(2)           Only require information or verification necessary to establish eligibility for assistance;

(3)           Make at least two requests for all necessary information from the applicant or third party;

(4)           Allow at least 12 calendar days between the initial request and a follow-up request and at least 12 calendar days between the follow-up request and denial of the application;

(5)           Inform the client in writing, and verbally when possible, of the right to request help in obtaining information requested from the client. The county department of social services shall not discourage any client from requesting such help;

(6)           An application may pend up to six months for verification that the deductible has been met or disability established.

(7)           When a hearing decision reverses the decision of the County Department of Social Services on an application, the application shall be reopened within five working days from the date the final appeal decision is received by the County Department of Social Services.  If no additional information is needed, the application must be processed within five additional working days.  If additional information is needed pursuant to the final decision, the county shall make such requests in accordance with rules for all applications.  The first request for the additional information shall be made within five working days of receipt of the final appeal decision.  The application shall be processed within five workdays of receipt of the last piece of required information.

(b)  The county department of social services shall obtain verification other than the applicant's statement for the following:

(1)           Any element requiring medical verification.  This includes verification of disability, pregnancy, incapacity, emergency dates for aliens referenced in 10A NCAC 23E .0102(c), incompetence, and approval of institutional care;

(2)           Proof a deductible has been met;

(3)           Legal alien status;

(4)           Proof of the rebuttal value for resources and of the rebuttal of intent to transfer resources to become eligible for Medicaid.  When an applicant or recipient disagrees with the determination of the county department of social services on the value of an asset, then the applicant/recipient must provide proof of what the value of the asset is;

(5)           Proof of designation of liquid assets for burial;

(6)           Proof of legally binding agreement limiting resource availability;

(7)           Proof of valid social security number or application for a social security number;

(8)           Proof of reserve reduction when resources exceed the allowable reserve limit for Medicaid;

(9)           Proof of earned and unearned income, including deductions, exclusions, and operational expenses when the applicant or Income Maintenance Caseworker has or can obtain the verification; and

(10)         Any other information for which the applicant does not know or cannot give an estimate.

(c)  The county department of social services shall verify or obtain an item of information when:

(1)           A fee must be paid to obtain the verification;

(2)           It is available within the agency;

(3)           The county department of social services is required by federal law to assist or to use interagency or intra-agency verification aids;

(4)           The applicant requests assistance; or

(5)           The applicant is physically, mentally, or otherwise incapable of obtaining the information, or is unable to speak English or read and write, or is housebound, hospitalized, or institutionalized, and a representative does not accept responsibility for obtaining the information.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.911; Alexander v. Flaherty, V.S.D.C., W.D.N.C., File No. C-C-74-183, Consent Order Filed 15 December 1989; Alexander v. Flaherty Consent Order filed February 14, 1992; Alexander v. Bruton Consent Order dismissed Effective February 1, 2002;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0203 Eff. May 1, 2012.

 

10A NCAC 23C .0202       MONITORING THRESHOLDS AND CORRECTIVE ACTION

(a)  Division of Medical Assistance employees, known as application monitors, shall review a random sample of applications in all county departments of social services and the Disability Determination Section (DDS) of the Division of Vocational Rehabilitation to determine if counties are denying and withdrawing applications in accordance with federal/state rules.  The application monitors shall also review inquiries where a person comes to the agency and decides not to make an application to ensure person was given correct information under federal/state rules.  A county and DDS must meet a monitoring threshold of 80% in each area of denials, withdrawals and inquiries in order to be found in compliance with federal/state rules.

(b)  If the agency falls below the 80% threshold, the agency must analyze why it fell below 80% and implement a corrective action plan.  

(c)  The agency or DDS may dispute monitoring findings within 10 workdays of receipt of findings.

(d)  Within 30 calendar days of the final monitoring results, the agency must take corrective action to reopen cases the application monitors determine were not handled pursuant to federal/state rules.

 

History Note:        Authority G.S. 108A-54; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Temporary Adoption Eff. March 1, 2003;

Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0605 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0203       timeliness

(a)  Every month, each county department of social services and the Disability Determination Section (DDS) of the Division of Vocational Rehabilitation shall process applications as follows:

(1)           The average processing time (APT) for the county department of social services shall be 90 days for M-AD and 45 days for all other aid program categories.

(2)           APT for DDS shall be 70 days.

(3)           The percentage processed timely (PPT) standard for county departments of social services:  Level I counties must process 85% of applications within the 45/90 day time standard.  Level II and III counties must process 90% of applications within the 45/90 day time standard.  Counties are classified as Levels I through III based on population of the county with Level I counties as the smallest in population while Level III counties are the largest in population size.

(4)           PPT standard for DDS:  DDS must render a decision within 70 days on 85% of cases for Level I counties and 90% of cases for Level II and III counties.  For county levels refer to the table below.

COUNTY    LEVELS

ALAMANCE (II)

CUMBERLAND (III)

JOHNSTON (II)

RANDOLPH (II)

 

 

 

 

ALEXANDER (I)

CURRITUCK (I)

JONES (I)

RICHMOND (I)

 

 

 

 

ALLEGHANY (I)

DARE (I)

LEE (I)

ROBESON (II)

 

 

 

 

ANSON (I)

DAVIDSON (II)

LENOIR (II)

ROCKINGHAM (II)

 

 

 

 

ASHE (I)

DAVIE (I)

LINCOLN (I)

ROWAN (II)

 

 

 

 

AVERY (I)

DUPLIN (II)

MACON (I)

RUTHERFORD (II)

 

 

 

 

BEAUFORT (II)

DURHAM (III)

MADISON (I)

SAMPSON (II)

 

 

 

 

BERTIE (I)

EDGECOMBE (II)

MARTIN (I)

SCOTLAND (II)

 

 

 

 

BLADEN (I)

FORSYTH (III)

MCDOWELL (I)

STANLY (I)

 

 

 

 

BRUNSWICK (II)

FRANKLIN (I)

MECKLENBURG (III)

STOKES (I)

 

 

 

 

BUNCOMBE (III)

GASTON (III)

MITCHELL (I)

SURRY (II)

 

 

 

 

BURKE (II)

GATES (I)

MONTGOMERY (I)

SWAIN (I)

 

 

 

 

CABARRUS (II)

GRAHAM (I)

MOORE (II)

TRANSYLVANIA (I)

 

 

 

 

CALDWELL (II)

GRANVILLE (I)

NASH (II)

TYRRELL (I)

 

 

 

 

CAMDEN (I)

GREENE (I)

NEW HANOVER (III)

UNION (II)

 

 

 

 

CARTERET (II)

GUILFORD (III)

NORTHAMPTON (I)

VANCE (II)

 

 

 

 

CASWELL (I)

HALIFAX (II)

ONSLOW (II)

WAKE (III)

 

 

 

 

CATAWBA (III)

HARNETT(II)

ORANGE (II)

WARREN (I)

 

 

 

 

CHATHAM (I)

HAYWOOD (II)

PAMLICO (I)

WASHINGTON (I)

 

 

 

 

CHEROKEE (I)

HENDERSON (II)

PASQUOTANK (I)

WATAUGA (I)

 

 

 

 

CHOWAN (I)

HERTFORD (I)

PENDER (I)

WAYNE (II)

 

 

 

 

CLAY (I)

HOKE (I)

PERQUIMANS (I)

WILKES (II)

 

 

 

 

CLEVELAND (II)

HYDE (I)

PERSON (I)

WILSON (II)

 

 

 

 

COLUMBUS (II)

IREDELL (II)

PITT (II)

YADKIN (I)

 

 

 

 

CRAVEN (II)

JACKSON (I)

POLK (I)

YANCEY (I)

(b)  If a county department of social services fails to meet the standards in Paragraph (a) of this Rule, the county shall analyze the reason for failure, document findings and work with the Medicaid Program Representative (MPR) to achieve corrective action.  The MPR is a Division of Medical Assistance employee.

(c)  Failure to meet the time standards in Paragraph (a) of this Rule, monthly shall result in corrective action to alleviate problems as outlined in Rules .0204 and .0205 of this Section.  Once eligibility is determined except for the following requirements:

(1)           sufficient medical expenses to meet a deductible; or

(2)           the determination of need for institutionalization; or

(3)           the plan of care for the home and community based waivers; or

(4)           the disability decision made by the Disability Determination Section; or

(5)           medical records needed to determine emergency dates for non-qualified aliens;

days shall be excluded from the time standard of 45 or 90 days.  Days in the time standard are again included when the items in Subparagraph (c)(1) through (5) are received until the application is completed with a written notice to the applicant.  When the 45/90th day falls on a weekend or holiday, the next workday in the month is considered the 45/90th day.

 

History Note:        Authority G.S. 108A-54; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Temporary Adoption Eff. March 1, 2003;

Adoption Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0606 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0204       local corrective action team

(a)  The Assistant Director for Recipient and Provider Services (R&PS) in the Division of Medical Assistance shall determine that a Local Corrective Action Team is needed when the county department of social services (DSS) is out of compliance with the monitoring or APT or PPT processing thresholds in any category for three consecutive months, or, five months out of any 12 consecutive months. The Local Corrective Action Team shall include the Medicaid Program Representative and any additional state staff identified by the Assistant Director for R&PS, the county department of social services director and any county staff the county director designates, the county manager or the chair of the county board of commissioners as selected by the county director, a member of the general public as selected by the county director, the social services board chairman or other board member for the county as selected by the county director, and an independent management consultant at the option and expense of the county.

(b)  A Local Corrective Action Team shall not convene when:

(1)           All failures are attributable to DDS.

(2)           It is determined by DMA Assistant Director for Recipient and Provider Services that the reasons for non-compliance have been or are being corrected.

(3)           Budgetary constraints decided by DMA Assistant Director for R&PS do not allow travel for the purpose of convening a corrective action team.  Conference calls shall be held by the DMA Assistant Director for R&PS when travel is not allowed as determined by State officials due to fiscal constraints.

(c)  The Local Corrective Action Team may design any remedy reasonable and necessary to bring the DSS into compliance with application processing requirements as in 10A NCAC 21B .0204 and this Subchapter.

(d)  The Team shall establish a corrective action plan within 40 calendar days of notice from the Assistant Director of Recipient and Provider Services to the county director of social services that a local corrective action team was required, and a date for compliance with the plan shall be set.  The corrective action plan must be submitted to the Assistant Director for R&PS.  The county must meet the thresholds in 10A NCAC 23C .0203(a) within three months after the date the compliance plan was required to be established.

(e)  Failure of a county to take corrective action, or meet compliance thresholds shall result in a referral by the Division of Medical Assistance to a State Corrective Action Team, unless the State Corrective Action Team grants an extension, not to exceed three months, for the county to meet the thresholds.  In determining if an extension shall be granted, the State Corrective Action Team shall receive a recommendation from the Division of Medical Assistance to grant an extension based on the Division's assessment that the county is taking action to comply with the corrective action plan.  The State Corrective Action Team shall be formed by the Secretary for the Department of Health and Human Services based on a request from the Division of Medical Assistance.  The State Corrective Action Team shall consist of a representative from the Department of Health and Human Services appointed by the Secretary, a representative of the NC Association of County Commissioners, two representatives from county departments of social services, excluding the county in question, appointed by the presidents of the following associations:  NC Social Services Association, NC Association of County Directors of Social Services, and the NC Association of County Boards of Social Services, the chairman of the Board of Legal Services of North Carolina or his designee, a recipient of Medicaid appointed by the Secretary, and a representative of the Institute of Government.

 

History Note:        Authority G.S. 108A-54; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Temporary Adoption Eff. March 1, 2003;

Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0607 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23C .0205       state corrective action team

(a)  A State Corrective Action Team shall be convened by the Chairperson within 10 days when:

(1)           The county department of social services (DSS) has failed to meet the compliance thresholds by the date established by the local corrective action team.

(2)           A local corrective action team requests an extension of time, not to exceed three months, to meet the compliance thresholds.

(3)           DDS fails to meet its compliance thresholds for three consecutive months or five out of 12 consecutive months.

(b)  The State Corrective Action Team may design any remedy reasonable and necessary to bring the DSS or DDS into compliance with application processing requirements in 10A NCAC 21B .0204 and this Subchapter.  This includes employing additional staff, altering office procedures (such procedures must be consistent with federal and state regulations, laws and Departmental rules), purchasing office equipment, retaining private consultants, reopening of cases, ordering retroactive relief to applicants harmed by violation of application processing requirements, and ordering the State to assist in the operation of a county department.

(c)  The State Corrective Action Team shall establish a corrective action plan for the DSS or DDS within 45 calendar days of convening.  A date for compliance shall be established.  The county or DDS must meet the thresholds in 10A NCAC 23C .0203(a) within three months after the date the team was convened.

(d)  Failure to achieve compliance shall result in a request from the Division of Medical Assistance to the Local Government Commission to assess and determine the capacity of the county to expend resources to bring the county into compliance.

 

History Note:        Authority G.S. 108A-54; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Temporary Adoption Eff. March 1, 2003;

Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0608 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

 

 

subchapter 23D – MEDICAID ELIGIBILITY GROUPS AND CLASSIFICATION

 

SECTION .0100 – COVERAGE GROUPS

 

10A NCAC 23d .0101       MANDATORY GROUPS

The following groups required by 42 U.S.C. 1396a (a)(10) or 1396u-1 shall be eligible for Medicaid:

(1)           Individuals who meet the requirements under 42 U.S.C. 1396u-1.

(2)           Individuals receiving four months continued Medicaid when eligibility under 42 U.S.C. 1396u-1 is lost due to collection or increased collection of child support.

(3)           Individuals receiving transitional Medicaid as described in 42 U.S.C. 1396s when eligibility under 42 U.S.C. 1396u-1 is lost due to increased earnings.

(4)           Individuals for whom an adoption assistance agreement is in effect or foster care maintenance payments are being made under Title IV E of the Social Security Act as described at 42 U.S.C. 673 (b).

(5)           Qualified pregnant women as defined at 42 U.S.C. 1396d(n)(1).

(6)           Qualified children as defined at 42 U.S.C. 1396d(n)(2).

(7)           Pregnant women, during a 60 day period following termination of the pregnancy, for pregnancy related and post partum services if they applied for Medicaid prior to termination of the pregnancy and were eligible on the date pregnancy is terminated.

(8)           Children, born to a woman who was eligible for and receiving Medicaid on the date of the child's birth, for up to one year from the date of birth; as described at 42 U.S.C. 1396a(e)(4).

(9)           Individuals receiving SSI under Title XVI of the Social Security Act.

(10)         Individuals who meet the requirements under 42 U.S.C. 1382h(a) or (b)(1).

(11)         Blind or disabled individuals who were eligible in December 1973 as blind or disabled and who for each consecutive month since December 1973 continue to meet December 1973 eligibility criteria.

(12)         Individuals who were eligible in December 1973 as aged, or blind, or disabled with an essential spouse and who, for each consecutive month since December 1973, continue to live with the essential spouse and meet December 1973 eligibility criteria.

(13)         Individuals who in December 1973 were eligible as the essential spouse of an aged, or blind, or disabled individual and who for each consecutive month since December 1973, have continued to live with that individual who has met December 1973 eligibility criteria.

(14)         Qualified Medicare Beneficiaries described at 42 U.S.C. 1396d(p).

(15)         Pregnant women whose countable income does not exceed the percent of the income official poverty line, established at 42 U.S.C. 1396a(1)(2), for pregnancy related services including labor and delivery.

(16)         Children born after September 30, 1983 and who are under age 19 who are described at 42 U.S.C. 1396a(1).

(17)         Qualified Disabled and Working Individuals described at 42 U.S.C. 1396d(s).

(18)         Individuals as described at 42 U.S.C. 1396a(a)(10)(E)(iii).

(19)         Individuals who would continue to be eligible for SSI except for specific Title II benefits or cost-of-living adjustments as described at 42 U.S.C. 1383c.

 

History Note:        Authority G.S. 108A-54; 42 U.S.C. 1396a(a)(10); 42 U.S.C. 1396a(e)(4); 42 U.S.C. 1396a(f); 42 C.F.R. 435.110; 42 C.F.R. 435.112; 42 C.F.R. 435.113; 42 C.F.R. 435.114; 42 C.F.R. 435.115; 42 C.F.R. 435.116; 42 C.F.R. 435.117; 42 C.F.R. 435.118; 42 C.F.R. 435.121; 42 C.F.R. 435.131; 42 C.F.R. 435.132; 42 C.F.R. 435.133;

Eff. September 1, 1984;

Amended Eff. January 1, 1995; March 1, 1993; January 4, 1993; April 1, 1992;

Temporary Amendment September 13, 1999;

Temporary Amendment Expired June 27, 2000;

Temporary Amendment September 12, 2000;

Amended Eff. August 1, 2002;

Transferred from 10A NCAC 21B .0101 Eff. May 1, 2012.

10A ncac 23D .0102       OPTIONAL GROUPS

The following optional groups of individuals described by 42 U.S.C. 1396a(a)(10)(A)(ii) and 42 U.S.C. 1396a(a)(10)(C) shall be eligible for Medicaid:

(1)           Children:

(a)           Children under age one whose family income is more than the amount established under Item (16), Rule .0101 of this Section and not more than a percent of the federal poverty level established by the General Assembly;

(b)           Children under age 21 who meet the eligibility requirements of this Subchapter;

(c)           Qualified children under age 19 as described in Item (6), Rule .0101 of this Section, who were born on or before September 30, 1983, and whose income is not more than 100% of the federal poverty level;

(d)           Adopted children under age 18 with special needs, as described at 42 U.S.C. 1396a(a)(10)(A)(ii)(VIII).

(2)           Individuals receiving optional state supplemental payment.

(3)           Caretaker relatives of eligible dependent children.

(4)           Pregnant women:

(a)           Whose countable income is more than the amount established under Item (15), Rule .0101 of this Section and not more than a percent of the federal poverty level established by the General Assembly, or

(b)           Who, if their countable income exceeds the percent of the federal poverty level, established in Sub-item (4)(a) of this Rule, meet the eligibility criteria for medically needy set forth in this Subchapter.

(5)           Aged, blind and disabled individuals whose income is at or below 100% of the Federal Poverty Level, adjusted each April 1, and who meet the resource requirements of SSI, but who do not receive cash assistance.

(6)           Women, as described at 42 U.S.C. 1396a(a)(10)(A)(ii)(XVIII) who:

(a)           have been screened for breast or cervical cancer under the Centers for Disease Control and Prevention breast and cervical cancer early detection program established under Title XV of the Public Health Service Act in accordance with the requirements of section 1504 of that Act and need treatment for breast or cervical cancer, including a precancerous condition of the breast or cervix;

(b)           are not otherwise covered under creditable coverage, as defined in section 2701(c) of the Public Health Service Act;

(c)           are not otherwise eligible for Medicaid; and

(d)           have not attained age 65.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.210; 42 C.F.R. 435.222; 42 C.F.R. 435.230; 42 C.F.R. 435.301; 42 C.F.R. 435.308; 42 C.F.R. 435.322; 42 C.F.R. 435.330; 42 U.S.C. 1396(a)(10)(A)(ii); 42 U.S.C. 1396a(a)(10)(C); S.L. 1983, c. 1034, s. 62.2; S.L. 1987, c. 738, s. 69 and 70; S.L. 1989, c. 752, s. 133;

Eff. September 1, 1984;

Amended Eff. February 1, 1992; July 1, 1991; August 1, 1990;

Temporary Amendment Eff. September 12, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Temporary Amendment Eff. October 1, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Amended Eff. January 1, 1995;

Temporary Amendment Eff. February 23, 1999;

Amended Eff. August 1, 2000;

Temporary Amendment Eff. January 1, 2002;

Amended Eff. April 1, 2003;

Transferred from 10A NCAC 21B .0102 Eff. May 1, 2012.

 

section .0200 - classification

 

10A NCAC 23d .0201       CLASSIFICATION

(a)  The following individuals shall be classified as categorically needy:

(1)           Individuals described in Item (1) of Rule .0101 of this Subchapter;

(2)           Deemed recipients of SSI described in Item (19) of Rule .0101 of this Subchapter; and individuals who are eligible for public assistance cash payments but who choose not to apply for cash payments;

(3)           Individuals described in Items (2), (3), and (4) of Rule .0101 of this Subchapter;

(4)           Pregnant women described in:

(A)          Item (5) or (15) of Rule .0101 of this Subchapter; or

(B)          Sub-item (1)(d) of Rule .0102 of this Subchapter;

(5)           Individuals under 21 described in:

(A)          Item (6) or (16) of Rule .0101 of this Subchapter; or

(B)          Sub-item (1)(a) of Rule .0102 of this Subchapter; or

(C)          Sub-item (1)(d) of Rule .0102 of this Subchapter who meet the eligibility requirements for categorically needy in this Subchapter;

(6)           Qualified Medicare Beneficiaries described in Item (14) of Rule .0101 of this Subchapter;

(7)           Individuals described in Item (11), (12), or (13) of Rule .0101 of this Subchapter who were receiving cash assistance payments in December 1973;

(8)           Individuals described in Item (7) of Rule .0101 of this Subchapter who were classified categorically needy when pregnancy terminated;

(9)           Individuals described in Item (8) of Rule .0101 of this Subchapter whose mother is classified as categorically needy;

(10)         Individuals described in Sub-item (1)(c) of Rule .0102 of this Subchapter; or

(11)         Individuals described in Sub-item (1)(d) of Rule .0102 of this Subchapter.

(b)  The following individuals who are not eligible as categorically needy and meet the requirements for medically needy set forth in this Subchapter shall be classified medically needy:

(1)           Pregnant women described in:

(A)          Item (7) of Rule .0101 of this Subchapter who were classified medically needy when their pregnancy terminated; or

(B)          Sub-item (4)(b) of Rule .0102 of this Subchapter;

(2)           Individuals under age 21;

(3)           Caretaker relatives of eligible dependent children; or

(4)           Aged, blind or disabled individuals not eligible for a public assistance cash payment.

 

History Note:        Filed as a Temporary Amendment Eff. October 1, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Filed as a Temporary Amendment Eff. September 12, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner;

Authority G.S. 108A-54; 42 C.F.R. 435.2; 42 C.F.R. 435.4;

Eff. September 1, 1984;

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

Temporary Amendment Eff. September 13, 1999;

Temporary Amendment Expired June 27, 2000;

Temporary Amendment Eff. September 12, 2000;

Amended Eff. August 1, 2002;

Transferred from 10A NCAC 21B .0408 Eff. May 1, 2012.

 

 

 

subchapter 23e – medicaid eligibility requirements

 

SECTION .0100 – non-financial requirements

 

10A NCAC 23E .0101       AGE

(a)  Pregnant women and caretaker relatives shall have no age requirement to be eligible for Medicaid.

(b)  Other individuals shall meet one of the following age requirements to qualify for Medicaid:

(1)           Age 65 and above as an aged individual; or

(2)           Under age 65 as a disabled individual; or

(3)           Under age 21.

(c)  The anniversary of birth shall be the method for determining when an age is reached.

(d)  July 1 shall be the date of birth when the year, but not the date of birth is known.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.520; Alexander v. Flaherty Consent Order filed

February 14, 1992;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990;

Transferred from 10A NCAC 21B .0301 Eff. May 1, 2012.

10A NCAC 23E .0102       UNITED STATES CITIZEN

(a)  The services covered by Medicaid for eligible clients shall be based on citizenship or alien status.

(b)  The following groups who meet all other eligibility criteria shall be eligible for all Medicaid services in the state plan:

(1)           United States citizens; or

(2)           A qualified alien as described in Section 431 of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (P.L. 104-93).

(c)  An alien not identified in Paragraph (b) of this Rule shall be eligible for Medicaid for care and services necessary for the treatment of an emergency condition if:

(1)           The alien requires the care and services after the sudden onset of a medical condition (including labor and delivery) that manifests itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could result in:

(A)          Placing the patient's health in serious jeopardy; or

(B)          Serious impairment to bodily functions; or

(C)          Serious dysfunction of any bodily organ or part.

(2)           The alien meets all other eligibility requirements for Medicaid.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.402; 8 U.S.C. 1161; 8 U.S.C. 1255a; 42 U.S.C. 1396b(v);

Eff. September 1, 1984;

Amended Eff. August 1, 2000; December 1, 1991; August 1, 1990;

Transferred from 10A NCAC 21B .0302 Eff. May 1, 2012.

 

10A NCAC 23E .0103       RESIDENCE

(a)  The requirements stated in 42 CFR 435.403 shall apply to determine residence in the state except for provisions in Paragraph (b) of this Rule.

(b)  Residents of the state of Georgia who enter a long term care facility in N.C. within 40 miles of the resident state's border shall retain residence in the prior state.  Residents of N.C. who enter a long term care facility in Georgia within 40 miles of the N.C. border retain N.C. residency.

(c)  An individual visiting in the state without intent to remain shall be ineligible for Medicaid.

(d)  An individual who moves to another state and intends to remain living in that state shall not be eligible for N.C. Medicaid.

(e)  County residence:

(1)           Any client who moves from one county to another North Carolina county shall continue to receive assistance if eligible.

(2)           An individual ordinarily has residence in the county in which he resides.  However, if he is in a hospital, mental institution, intermediate care facility, skilled nursing home, boarding home, confinement center or similar facility, the county in which the facility is located shall not be his legal residence.  Except for (e)(3) in this Rule, the county of legal residence shall be the county in which the individual lived in a private living arrangement prior to entering a facility.

(3)           If an individual who became disabled prior to age 18 has remained in a facility, he remains a resident of the county and state in which his parent(s) had residence immediately prior to his reaching age 18.  If, as an adult, he is applying for assistance and it is not possible to trace his county of residence as a minor, he shall establish residence based on his intent to remain regardless of his parent's current legal residence.

(f)  The client's statement shall be accepted as verification unless there is reason to doubt it.  If there is doubt, evaluation of the statement shall be substantiated for:

(1)           Temporary absence by determination of the reason for absence, expected duration of the absence, and continued maintenance of home in county of residence;

(2)           Entering the state for employment purposes by verified employment, contacts with prospective employers, health department records, Employment Security Commission or Rural Manpower office registration, home in another state with lease or other legal agreement for rental or purchase, or documents proving separation from dependents in another state;

(3)           Intent to remain by documents proving disposition of home in prior state, auto registration and drivers license changed to N.C. within 30 days, change in address with former post office or other sources from which income is received and change in voter registration, tax listing;

(4)           Incapability of stating intent by verification of representative payee for benefit payments, receipt of benefits on basis of mental illness or retardation, care is provided in a mental retardation facility or power of attorney or guardian has been appointed for him.

 

History Note:        Authority G.S. 108A-54; G.S. 150B-14(c); 42 C.F.R. 435.403;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0303 Eff. May 1, 2012.

 

10A NCAC 23E .0104       DEPRIVATION

Deprivation shall be due to:

(1)           Death of either parent.

(2)           Physical or mental incapacity of either parent based on a physical or mental defect, illness, or impairment of such a debilitating nature as to reduce or eliminate the parent's ability to support or care for the otherwise eligible child; provided, that the defect, illness, or impairment shall be expected to last for at least 30 days.

(3)           Continued absence of parent for reason other than death or hospitalization, of not more than 12 months, and this absence interferes with the child's receipt of maintenance, physical care, or guidance from his parent and precludes the parent's being counted on for support or care for the child.  Such continued absence may be due to any of the following:

(a)           Divorce;

(b)           Separation;

(c)           Desertion or abandonment;

(d)           Absence from the home for treatment or medical care and the expected duration of the absence will exceed 12 months; and

(e)           Incarceration in an institution.

Temporary absence of the payee relative or of the child from the home shall not affect eligibility, if the absent member of the household has not established another abode of a permanent nature, and the reasons for absence indicate that the absence will be temporary.  A child may be temporarily absent from the home for various reasons, but the responsible relative shall have a plan documented in the record for bringing the child back into the home when the need for his absence has passed. The exercise of parental control and guidance by the relative, rather than the physical presence of the relative or the child in the home, shall be the important factor to be considered.

(4)           Parents living together and not married to each other where the putative father's duty to support the child has not been established.

(5)           Unemployed Status for Two-Parent Families.  The child shall be deprived if both parents are in the home and:

(a)           The parents are eligible for Medicaid because countable income is equal to or less than the appropriate categorically needy income limit as defined in Rule .0203(e) of this Subchapter; or

(b)           The parents are eligible for Medicaid under medically needy eligible criteria by virtue of meeting a deductible based upon income which exceeds the appropriate income limit as defined in Rule .0203(e) of this Subchapter.

 

History Note:        Authority G.S. 108A-28; 108A-54; 42 C.F.R. 435.510; 89 CVS 922;

Eff. September 1, 1984;

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

Temporary Amendment Eff. August 5, 1999;

Amended Eff. March 19, 2001;

Transferred from 10A NCAC 21B .0304 Eff. May 1, 2012.

 

10A NCAC 23E .0105       DISABILITY

(a)  Individuals eligible for Medicaid in December 1973 as disabled individuals and who meet conditions required by 42 CFR 435.133 shall be permanently and totally disabled based on a physical or mental impairment which substantially precludes him from obtaining gainful employment, and such impairment appears reasonably certain to continue without substantial improvement throughout his life time.

(b)  Any client who has applied for Medicaid since January 1, 1974 on the basis of disability shall be found disabled under the definition of disability and procedures established for evaluation of vocational and medical factors under the supplemental security income program.

(c)  A social history on a form prescribed by the state shall be completed by the Income Maintenance Caseworker and submitted to the Disability Determination Section with the request for disability determination.

(d)  Except for client's receiving social security or supplemental security income on the basis of disability, the decision on disability is made by the Disability Determination Section of the Division of Social Services.

(e)  Social Security Administration (SSA) decisions made for social security disability or supplemental security income shall be adopted for persons applying for Medicaid.

(f)  Disability determination shall be verified from the client's award letter, SDX, BENDEX, Disability Determination Section approval, Administrative Law Judge decision or other documentary evidence.

(g)  Disability for purposes of Medicaid eligibility shall cease when the client is determined by the Social Security Administration or the Disability Determination Section to be capable of engaging in substantial gainful activity.  The client may appeal the termination of Medicaid based on his disability cessation.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.540; 42 C.F.R. 435.541; Alexander v. Flaherty Consent Order filed February 14, 1992;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990;

Transferred from 10A NCAC 21B .0305 Eff. May 1, 2012.

 

10A NCAC 23E .0106       BLINDNESS

(a)  To qualify for Medicaid under the category of Aid to the Blind, the client shall meet one of the following conditions:

(1)           Was receiving Medicaid on the basis of blindness in December 1973, has been continuously eligible for Medicaid since that date and has been determined by the State disability determination unit to have visual acuity of 20/100 in the better eye with correction or visual field limitation in the better eye of 30 percent or less;

(2)           Has applied for Medicaid since January 1, 1974 and meets the definition of blindness, vocational and medical factors applied under the Supplemental Security Income Program.

(b)  For clients applying for Medicaid since January 1, 1974 blindness shall be determined by one of the following methods:

(1)           Documentary evidence including SDX, BENDEX, or an award letter that social security benefits, supplemental security income or veterans benefits have been awarded on the basis of blindness;

(2)           A written decision from the physician consultant of the Division of Services for the Blind based on review of a medical eye examination report.

(c)  Blindness shall be reverified for clients determined eligible under Paragraph (b) of this Rule at each review of the client's eligibility or when reexamination is recommended by the physician consultant.

(d)  The client shall cease to qualify for Medicaid as blind individual when evidence is received from any of the sources described in Paragraphs (a)(1) or (b) of this Rule that the client no longer meets the definition of blindness.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.530; 42 C.F.R. 435.531;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0306 Eff. May 1, 2012.

 

10A NCAC 23E .0107       CARETAKER RELATIVE

(a)  To qualify for Medicaid as a caretaker relative the individual shall be the natural or adoptive parent or the specified relative living in the household with the child if the caretaker is:

(1)           Pregnant with no other dependent children in her care, or

(2)           Related to an eligible child, who is deprived as described in Rule .0104 of this Section, and

(3)           Provide day to day care and supervision for the child.

(b)  Pregnancy shall be medically verified and the length of pregnancy and expected delivery date indicated on the medical statement.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.310;

Eff. September 1, 1984;

Amended Eff. April 1, 1993; August 1, 1990;

Transferred from 10A NCAC 21B .0307 Eff. May 1, 2012.

 

10a NCAC 23E .0108       INMATE OF PUBLIC INSTITUTION OR PRIVATE PSYCHIATRIC HOSPITAL

Individuals living in a public institution as defined in 10A NCAC 23A .0102, or a privately owned hospital shall be ineligible for Medicaid unless they are:

(1)           Age 65 or over and in a state mental institution, or

(2)           Under age 21 and receiving inpatient psychiatric services, or

(3)           Age 21 through age 64 and in the medical or surgical unit of a state mental hospital.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.1008; 42 C.F.R. 435.1009; S.L. 1987, c. 758, s. 69;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0308 Eff. May 1, 2012.

 

section .0200 – financial requirements

 

10A NCAC 23E .0201       APPLYING FOR ALL BENEFITS AND ANNUITIES

(a)  Clients shall take all necessary steps to obtain any annuities, pensions, retirement and disability benefits to which they are entitled, unless they have good cause for not doing so.

(b)  Good cause is limited to physical or mental incapability to make such effort.

(c)  The amount of any verifiable benefits is counted as income to the client if the amount can be determined.  If the amount cannot be determined, but the availability is verified, the case shall be denied or terminated for client's failure to cooperate.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.603;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0309 Eff. May 1, 2012.

 

10A NCAC 23E .0202       RESERVE

(a)  North Carolina has contracted with the Social Security Administration under Section 1634 of the Social Security Act to provide Medicaid to all SSI recipients.  Resource eligibility for individuals under any Aged, Blind, and Disabled coverage group shall be determined based on standards and methodologies in Title XVI of the Social Security Act except as specified in Paragraphs (k) and (l) of this Rule.  Applicants for and recipients of Medicaid shall use their own resources to meet their needs for living costs and medical care to the extent that such resources can be made available.

(b)  The value of resources currently available to any budget unit member shall be considered in determining financial eligibility.  A resource shall be considered available when it is actually available and when the budget unit member has a legal interest in the resource and he, or someone acting in his behalf, can take any necessary action to make it available.

(c)  Resources shall be excluded in determining financial eligibility when the budget unit member having a legal interest in the resources is incompetent unless:

(1)           A guardian of the estate, a general guardian or an interim guardian has been lawfully appointed and is able to act on behalf of his ward in North Carolina and in any state in which such resources are located; or

(2)           A durable power of attorney, valid in North Carolina and in any state in which such resource is located, has been granted to a person who is authorized and able to exercise such power.

(d)  When there is a guardian, an interim guardian, or a person holding a valid, durable power of attorney for a budget unit member, but such person is unable, fails, or refuses to act promptly to make the resources actually available to meet the needs of the budget unit member, a referral shall be made to the county department of social services for a determination of whether the guardian or attorney in fact is acting in the best interests of the member and if not, the county department of social services shall contact the clerk of court for intervention.  The resources shall be excluded in determining financial eligibility pending action by the clerk of court.

(e)  When a Medicaid application is filed on behalf of an individual who:

(1)           is alleged to be mentally incompetent,

(2)           has or may have a legal interest in a resource that affects the individual's eligibility, and

(3)           does not have a representative with legal authority to use or dispose of the individual's resources, the individual's representative or family member shall be instructed to file within 30 calendar days a judicial proceeding under G.S. 35A to declare the individual incompetent and appoint a guardian.  If the representative or family member either fails to file such a proceeding within 30 calendar days or fails to timely conclude the proceeding, a referral shall be made to the services unit of the county department of social services for guardianship services.  If the allegation of incompetence that has lasted, or is expected to last 30 consecutive days or more, or until the individual's death, is supported by competent evidence, as specified in Paragraph (h) of this Rule, the resources shall be excluded beginning with the date that such evidence indicates that he became incompetent, except as provided in Paragraphs (f) or (g) of this Rule. 

(f)  The budget unit member's resources shall be counted in determining his eligibility for Medicaid beginning the first day of the month following the month a guardian of the estate, general guardian or interim guardian is appointed, provided that after the appointment, property that cannot be disposed of or used except by order of the court shall continue to be excluded until completion of the applicable procedures for disposition specified in G.S. 1 or G.S. 35A.

(g)  When the court rules that the budget unit member is competent or no ruling is made because of the death or recovery of the member, his resources shall be counted except for periods of time for which it can be established by competent evidence specified in Paragraph (h) of this Rule, that the member was in fact incompetent for at least 30 consecutive days, or until his death.  Any such showing of incompetence is subject to rebuttal by competent evidence as specified in Paragraph (h) of this Rule.

(h)  For purposes of this Rule, competent evidence is limited to the written statement or testimony at a competency hearing of a physician, psychologist, nurse, or social worker with knowledge of the condition of the individual, the basis of that knowledge, the beginning date of incompetence, the reason the individual is incompetent, and if no longer incompetent, when the individual recovered competence.

(i)  The limitation of resources held for reserve for the budget unit shall be as follows:

(1)           for Family and Children's related categorically and medically needy cases, three thousand dollars ($3,000.00) per budget unit;

(2)           for aged, blind, and disabled cases, two thousand dollars ($2000.00) for a budget unit of one and three thousand dollars ($3000.00) for a budget unit of two.

(j)  If the value of countable resources of the budget unit exceeds the reserve allowance for the unit, the case shall be ineligible:

(1)           For Family and Children's related cases and aged, blind or disabled cases protected by grandfathered provisions, and medically needy cases not protected by grandfathered provision, eligibility shall begin on the day countable resources are reduced to allowable limits or excess income is spent down, whichever occurs later;

(2)           For categorically needy aged, blind or disabled cases not protected by grandfathered provisions, eligibility shall begin no earlier than the month countable resources are reduced to allowable limits as of the first moment of the first day of the month.

(k)  Resources counted in the determination of financial eligibility for categorically needy aged, blind and disabled cases, and Qualified Medicare Beneficiaries, Specified Low-Income Medicare Beneficiaries, Qualifying Individual and Qualified Disabled Working Individual cases shall be based on resource standards and methodologies in Title XVI of the Social Security Act except for the following methodologies:

(1)           The value of personal effects and household goods shall be not counted.

(2)           Value of tenancy in common interest in real property shall be not counted.

(3)           Value of life estate interest in real property shall be not counted.

(4)           Value of burial plots shall be not counted.

(5)           The cash value of life insurance when the total face value of all cash value bearing life insurance policies does not exceed ten thousand dollars ($10,000.00) shall be not counted.

(l)  Resources counted in the determination of financial eligibility for medically needy aged, blind and disabled cases is based on resource standards and methodologies in Title XVI of the Social Security Act except for the following methodologies:

(1)           The value of personal effects and household goods shall be not counted.

(2)           Value of tenancy in common interest in real property shall be not counted.

(3)           Value of life estate interest in real property is not counted.

(4)           Individuals with resources in excess of the resource limit at the first moment of the month may become eligible at the point that resources are reduced to the allowable limit.

(5)           Value of burial plots shall be not counted.

(6)           The cash value of life insurance when the total face value of all cash value bearing life insurance polities does not exceed ten thousand dollars ($10,000.00) shall be not counted.

(m)  Resources counted in the determination of financial eligibility for categorically needy Family and Children's related cases shall be:

(1)           Cash on hand;

(2)           The balance of savings accounts, including savings of a student saving his earnings for school expenses;

(3)           The balance of checking accounts less the current monthly income that had been deposited to meet the budget unit's monthly needs when reserve was verified;

(4)           The portion of lump sum payments remaining after the month of receipt;

(5)           Cash value of life insurance policies owned by the budget unit;

(6)           Stocks, bonds, mutual fund shares, certificates of deposit and other liquid assets;

(7)           Patient accounts in long term care facilities;

(8)           Equity in non-essential personal property limited to:

(A)          Mobile homes not used as home;

(B)          Boats, boat trailers and boat motors;

(C)          Campers;

(D)          Farm and business equipment;

(E)           Equity in vehicles in excess of one motor vehicle per adult;

(n)  Resources counted in the determination of financial eligibility for medically needy Family and Children's related cases are:

(1)           Cash on hand;

(2)           The balance of savings accounts, including savings of a student saving his earnings for school expenses;

(3)           The balance of checking accounts less the current monthly income that had been deposited to meet the budget unit's monthly needs when reserve was verified or lump sum income from self‑employment deposited to pay annual expenses;

(4)           Cash value of life insurance policies when the total face value of all policies that accrue cash value exceeds one thousand five hundred dollars ($1,500.00);

(5)           Stocks, bonds, mutual fund shares, certificates of deposit and other liquid assets;

(6)           Patient accounts in long term care facilities;

(7)           Equity in non-essential, non-income producing personal property limited to:

(A)          Mobile home not used as home,

(B)          Boats, boat trailers and boat motors,

(C)          Campers,

(D)          Farm and business equipment,

(E)           Equity in motor vehicles in excess of one vehicle per adult if not income-producing.

 

History Note:        Authority G.S. 108A-54; 108A-55; 108A-58; 42 U.S.C. 703, 704 1396; 42 C.F.R. 435.121; 42 C.F.R. 435.210; 42 C.F.R. 435.711; 42 C.F.R. 435.712; 42 C.F.R. 435.734; 42 C.F.R. 435.823; 42 C.F.R. 435.840; 42 C.F.R. 435.841; 42 C.F.R. 435-845; 42 C.F.R. 445.850; 42 C.F.R. 435.851; 45 C.F.R. 233.20; 45 C.F.R. 233.51; S.L. 2002-126;

Eff. September 1, 1984;

Temporary Amendment Eff. September 1, 1985, for a period of 92 days to expire on December 1, 1985;

Amended Eff. January 1, 1995; November 1, 1994; September 1, 1993; March 1, 1993;

Temporary Amendment Eff. September 13, 1999;

Temporary Amendment Expired June 27, 2000;

Temporary Amendment Eff. September 12, 2000;

Amended Eff. March 19, 2001;

Temporary Amendment Eff. April 16, 2001;

Amended Eff. August 1, 2002;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21B .0310 Eff. May 1, 2012.

 

10A NCAC 23E .0203       INCOME

(a)  For family and children's cases, income from the following sources shall be counted in the calculation of financial eligibility:

(1)           Unearned.

(A)          RSDI,

(B)          Veteran's Administration,

(C)          Railroad Retirement,

(D)          Pensions or retirement benefits,

(E)           Workmen's Compensation,

(F)           Unemployment Compensation,

(G)          Support Payments,

(H)          Contributions,

(I)            Dividends or interest from stocks, bonds, and other investments,

(J)            Trust fund income,

(K)          Private disability or employment compensation,

(L)           That portion of educational loans, grants, and scholarships for maintenance,

(M)         Work release,

(N)          Lump sum payments,

(O)          Military allotments,

(P)           Brown Lung Benefits,

(Q)          Black Lung Benefits,

(R)          Trade Adjustment benefits,

(S)           SSI when the client is in long term care,

(T)           VA Aid and Attendance when the client is in long term care,

(U)          Foster Care Board payments in excess of state maximum rates for M-AF clients who serve as foster parents,

(V)          Income allocated from an institutionalized spouse to the client who is the community spouse as stated in 42 U.S.C. 1396r-5(d),

(W)         Income allowed from an institutionalized spouse to the client who is a dependent family member as stated in 42 U.S.C. 1396r-5(d),

(X)          Sheltered Workshop Income,

(Y)          Loans if repayment of a loan and not counted in reserve,

(Z)           Income deemed to Family and Children's clients.

(2)           Earned Income.

(A)          Income from wages, salaries, and commissions,

(B)          Farm Income,

(C)          Small business income including self-employment,

(D)          Rental income,

(E)           Income from roomers and boarders,

(F)           Earned income of a child client who is a part-time student and a full-time employee,

(G)          Supplemental payments in excess of state maximum rates for Foster Care Board payments paid by the county to Family and Children's clients who serve as foster parents,

(H)          VA Aid and Attendance paid to a budget unit member who provides the aid and attendance.

(3)           Additional sources of income not listed in Subparagraphs (a)(1) or (2) of this Rule shall be considered available unless specifically excluded by Paragraph (b) of this Rule, or by regulation or statute.

(b)  For family and children's cases, income from the following sources shall not be counted in the calculation of financial eligibility:

(1)           Earned income of a child who is a part-time student but is not a full-time employee;

(2)           Earned income of a child who is a full-time student;

(3)           Incentive payments and training allowances made to WIN training participants;

(4)           Payments for supportive services or reimbursement of out-of-pocket expenses made to volunteers serving as VISTA volunteers, foster grandparents, senior health aides, senior companions, Service Corps of Retired Executives, Active Corps of Executives, Retired Senior Volunteer Programs, Action Cooperative Volunteer Program, University Year for Action Program, and other programs under Titles I, II, and III of Public Law 93-113;

(5)           Foster Care Board payments equal to or below the state maximum rates for Family and Children's clients who serve as foster parents;

(6)           Income that is unpredictable, i.e., unplanned and arising only from time to time.  Examples include occasional yard work and sporadic babysitting;

(7)           Relocation payments;

(8)           Value of the coupon allotment under the Food Stamp Program;

(9)           Food (vegetables, dairy products, and meat) grown by or given to a member of the household.  The amount received from the sale of home grown produce is earned income;

(10)         Benefits received from the Nutrition Program for the Elderly;

(11)         Food Assistance under the Child Nutrition Act and National School Lunch Act;

(12)         Assistance provided in cash or in kind under any governmental, civic, or charitable organization whose purpose is to provide social services or vocational rehabilitation.  This includes V.R. incentive payments for training, education and allowance for dependents, grants for tuition, chore services under Title XX of the Social Security Act, VA aid and attendance or aid to the home bound if the individual is in a private living arrangement;

(13)         Loans or grants such as the GI Bill, civic, honorary and fraternal club scholarships, loans, or scholarships granted from private donations to the college, etc., except for any portion used or designated for maintenance;

(14)         Loans, grants, or scholarships to undergraduates for educational purposes made or insured under any program administered by the U.S. Department of Education;

(15)         Benefits received under Title VII of the Older Americans Act of 1965;

(16)         Payments received under the Experimental Housing Allowance Program (EHAP);

(17)         In-kind shelter and utility contributions paid directly to the supplier.  For Family and Children's cases, shelter, utilities, or household furnishings made available to the client at no cost;

(18)         Food/clothing contributions in Family and Children's cases (except for food allowance for persons temporarily absent in medical facilities up to 12 months);

(19)         Income of a child under 21 in the budget unit who is participating in JTPA and is receiving as a child;

(20)         Housing Improvement Grants approved by the N.C. Commission of Indian Affairs or funds distributed per capital or held in trust for Indian tribe members under P.L. 92-254, P.L. 93-134 or P.L. 94-540;

(21)         Payments to Indian tribe members as permitted under P.L. 94-114;

(22)         Payments made by Medicare to a home renal dialysis patient as medical benefits;

(23)         SSI except for individuals in long term care;

(24)         HUD Section 8 benefits when paid directly to the supplier or jointly to the supplier and client;

(25)         Benefits received by a client who is a representative payee for another individual who is incompetent or incapable of handling his affairs.  Such benefits must be accounted for separate from the payee's own income and resources;

(26)         Special one time payments such as energy, weatherization assistance, or disaster assistance that is not designated as medical;

(27)         The value of the U.S. Department of Agriculture donated foods (surplus commodities);

(28)         Payments under the Alaska Native Claims Settlement Act, Public Law 92-203;

(29)         Any payment received under Title II of the Uniform Relocation Assistance and Real Property Acquisition Policies Act of 1970;

(30)         HUD Community Development Block Grant funds received to finance the renovation of a privately owned residence;

(31)         Reimbursement for transportation expenses incurred as a result of participation in the Community Work Experience Program or for use of client's own vehicle to obtain medical care or treatment;

(32)         Adoption assistance;

(33)         Incentive payments made to a client participating in a vocational rehabilitation program;

(34)         Title XX funds received to pay for services rendered by another individual or agency;

(35)         Any amount received as a refund of taxes paid;

(36)         The first fifty-dollars ($50) of each child support/spousal obligation or military allotment paid monthly to the budget unit in a private living arrangement.

(c)  For aged, blind, and disabled cases, income counted in the determination of financial eligibility is based on standards and methodologies in Title XVI of the Social Security Act.

(d)  For aged, blind, and disabled cases, income from the following sources shall not be counted:

(1)           Any Cost of Living Allowance (COLA) increase or receipt of RSDI benefit which resulted in the loss of SSI for those individuals described in 10A NCAC 23D .0101(17).

(2)           Earnings for those individuals who have a plan for achieving self-support (PASS) that is approved by the Social Security Administration.

(e)  Income levels for purposes of establishing eligibility are those amounts approved by the N.C. General Assembly and stated in the Appropriations Act for categorically needy and medically needy classifications, except for the following:

(1)           The income level shall be reduced by one-third when an aged, blind or disabled individual lives in the household of another person and does not pay his proportionate share of household expenses. The one-third reduction shall not apply to children under nineteen years of age who live in the home of their parents;

(2)           An individual living in a long term care facility or other medical institution shall be allowed as income level deduction for personal needs described under Rule .0204 (Personal Needs Allowance) of this Section;

(3)           The categorically needy income level for an aged, blind, and disabled individual or couple is 100% of the Federal Poverty Level;

(4)           The income level to be applied for Qualified Medicare Beneficiaries described in 42 U.S.C. 1396d and individuals described in 42 U.S.C. 1396e is based on the income level for one; or two for a married couple who live together and both receive Medicare.

 

History Note:        Filed as a Temporary Rule Effective July 1, 1987, for a period of 120 days to expire on October 31, 1987;

Authority G.S. 108A-25(b); 108A-61; 42 C.F.R. 435.135; 42 C.F.R 435.731; 42 C.F.R. 435.732; 42 C.F.R. 435.733; 42 C.F.R. 435.811; 42 C.F.R. 435-812; 42 C.F.R. 435.831; 42 C.F.R. 435.832; 42 C.F. 435.1007; 45 C.F.R. 233.20; 42 U.S.C 1383c(b); 42 U.S.C 1383c(d); P.L. 99-272; Section 12202; Alexander v. Flaherty Consent Order filed February 14, 1992;

Eff. September 1, 1984;

Amended Eff. January 1, 1996; January 1, 1995; September 1, 1994; September 1, 1993;

Temporary Amendment Eff. February 23, 1999;

Amended Eff. August 1, 2000;

Transferred from 10A NCAC 21B .0312 Eff. May 1, 2012.

 

10A NCAC 23E .0204       PERSONAL NEEDS ALLOWANCE

An individual living in a long term care facility or other medical institution shall be allowed an amount for personal needs.  The personal needs allowance is the sum of the following, but not to exceed the income maintenance level provided by statute for a single individual (or a couple, if in the same LTC room) in a private living arrangement.

(1)           Standard Personal Needs Amount:

(a)           A thirty dollar ($30.00) deduction for one individual; or

(b)           Sixty dollar ($60.00) deduction for a married couple in the same long term care facility; or

(c)           Ninety dollar ($90.00) deduction for a veteran (or the surviving spouse of a veteran) with no living dependents whose pension has been reduced to ninety dollars ($90.00) by the Veterans Administration;

(2)           Individuals With Greater Need:

(a)           Work Incentive Allowance:  Individuals who reside in an ICF or ICF-MR facility and who are regularly engaged in work activities as part of their developmental plan for which they receive otherwise countable wages shall be allowed an incentive deduction in the following amounts:

 

Monthly Net Wages                                                                            Incentive Allowance

 

$    1 to $100                                                                                        Up to $50

$101 to $200                                                                                        $ 80

$201 to $300                                                                                        $130

$301 and greater                                                                                 $212

 

(b)           Guardianship fees:  Individuals, for whom a guardian of the estate has been named by the court, shall be allowed, for payment of guardianship fees, whichever of the following amounts is less:

(i)            10% of total monthly income from all sources, both earned and unearned; or

(ii)           Twenty-five dollars ($25.00) per month.

 

History Note:        Authority G.S. 108A-25(b); 42 C.F.R. 435.135; 42 C.F.R. 435.731; 42 C.F.R. 435.732; 42 C.F.R. 435.733; 42 C.F.R. 435.831; 42 U.S.C. 1383c(b); 42 U.S.C. 1383c(d);

Eff. September 1, 1994;

Transferred from 10A NCAC 21B .0313 Eff. May 1, 2012.

 

10A NCAC 23E .0205       BUDGET UNIT MEMBERSHIP

Individuals who are required by law to be financially responsible for the support of each other or other dependents shall be included in the budget unit.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 435.602; 45 C.F.R. 233.51;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0401 Eff. May 1, 2012.

 

10A NCAC 23E .0206       FINANCIAL RESPONSIBILITY AND DEEMING

The income and resources of financially responsible persons are deemed available to the applicant or recipient in the following situations:

(1)           For aged, blind, and disabled individuals in a private living arrangement, financial responsibility and deeming of income and resources is based on methodologies in Title XVI of the Social Security Act.  This applies to:

(a)           spouses when living together or temporarily absent;

(b)           parents for disabled or blind children under age 18 who are living in the household with them or temporarily absent.

(2)           For aged, blind, and disabled individuals in a long term care living arrangement, financial responsibility and deeming of income is based on methodologies in Title XVI of the Social Security Act.  This applies to:

(a)           spouse to spouse only for the month of entry into a long term care facility;

(b)           parents for dependent children under age 18 in skilled nursing facilities, intermediate care facilities, intermediate care facilities for the mentally retarded, or hospitals whose care and treatment is not expected to exceed 12 months as certified by the patient's physician.

(3)           For aged, blind, and disabled individuals in a long term care living arrangement who have a spouse living in the community, treatment of income and resources is consistent with Section 1924 of the Social Security Act.

(4)           For AFDC related cases, except pregnant women described at 42 U.S.C. 1396(1), financial responsibility exists for:

(a)           spouses when living together or one spouse is temporarily absent in long term care;

(b)           parents for dependent children under age 21 living in the home with them or temporarily absent;

(c)           parents for dependent children under age 21 in nursing facilities or intermediate care facilities for the mentally retarded except when such care and treatment is expected to exceed 12 months as certified in writing by their attending physician;

(d)           parents for dependent children under age 21, in institutions for medical, surgical or inpatient psychiatric care, including inpatient treatment for substance abuse except when such care and treatment is expected to exceed 12 months as certified in writing by their attending physician and approved by the Division of Medical Assistance; and

(5)           For pregnant women described at 42 U.S.C. 1396(1) financial responsibility exists for:

(a)           The pregnant woman's spouse if living in the home or temporarily absent from the home;

(b)           The father of the unborn child if not married to the pregnant woman but living in the home and acknowledging paternity of the unborn child.

(6)           Parental financial responsibility for children in private living arrangements or long term care facilities for whom the county has legal custody or placement responsibility is based on court ordered support and voluntary contributions from the parents.

 

History Note:        Authority G.S. 108A-54; 143-127.1; S.L. 1983, c. 761, s. 60(6); S.L. 1983, c. 1034; S.L. 1983, c. 1116; 42 C.F.R. 435.602; 42 C.F.R. 435.712; 42 C.F.R. 435.734; 42 C.F.R. 435.821; 42 C.F.R. 435.823;

Eff. September 1, 1984;

Temporary Amendment Eff. April 1, 1990 for a period of 180 days to expire on September 30, 1990;

Amended Eff. January 1, 1995; September 1, 1992; October 1, 1990; August 1, 1990;

Temporary Amendment Eff. January 1, 2003;

Temporary Amendment Expired October 12, 2003;

Transferred from 10A NCAC 21B .0402 Eff. May 1, 2012.

 

10A NCAC 23E .0207       RESERVE

(a)  The value of resources held by the client or by a financially responsible person shall be considered available to the client in determining countable reserve for the budget unit.

(b)  Jointly owned resources shall be counted as follows:

(1)           The value of resources owned jointly with a non-financially responsible person who is a recipient of another public assistance budget unit shall be divided equally between the budget units;

(2)           The value of liquid assets and personal property owned jointly with a non-financially responsible person who is not a client of another public assistance budget unit shall be available to the budget unit member if he can dispose of the resource without the consent and participation of the other owner or the other owner consents to and, if necessary, participates in the disposal of the resource;

(3)           The client's share of the value of real property owned jointly with a non-financially responsible person who is not a member of another public assistance budget unit shall be available to the budget unit member if he can dispose of his share of the resource without the consent and participation of the other owner or the other owner consents to and, if necessary, participates in the disposal of the resource.

(c)  The terms of a separation agreement, divorce decree, will, deed or other legally binding agreement or legally binding order shall take precedence over ownership of resources as stated in (a) and (b) of this Rule, except as provided in Paragraph (k) of this Rule.

(d)  For all aged, blind, and disabled cases, the resource limit, financial responsibility, and countable and non-countable assets are based on standards and methodology in Title XVI of the Social Security Act except as specified in Items (4) and (5) in Rule .0202 of this Section.

(e)  Countable resources for Family and Children's related cases shall be determined as follows:

(1)           The resources of a spouse, who is not a stepparent, shall be counted in the budget unit's reserve allowance if the spouses live together or one spouse is temporarily absent in long term care and the spouse is not a member of another public assistance budget unit;

(2)           The resources of a client and a financially responsible parent or parents shall be counted in the budget unit's reserve limit if the parents live together or one parent is temporarily absent in long term care and the parent is not a member of another public assistance budget unit;

(3)           The resources of the parent or parents shall not be considered if a child under age 21 requires care and treatment in a medical institution and his physician certifies that the care and treatment are expected to exceed 12 months.

(f)  Real property shall be excluded from countable resources for Family and Children's related cases.

(g)  One motor vehicle per adult shall be excluded for Family and Children's related cases.

(h)  For medically needy family and children’s related cases, income producing vehicles and personal property shall be excluded from countable resources.

(i)  For family and children's related cases the value of non-excluded motor vehicles is the Current Market Value, less encumbrances.  If the applicant/recipient disagrees with the assigned value, he has the right to rebut the value.

(j)  For a married individual:

(1)           Resources available to the individual are available to his or her spouse who is a noninstitutionalized applicant or recipient and who is either living with the individual or temporarily absent from the home, irrespective of the terms of any will, deed, contract, antenuptial agreement, or other agreement, and irrespective of whether or not the individual actually contributed the resources to the applicant or recipient.  All resources available to an applicant or recipient under this Section must be considered when determining his or her countable reserve.

(2)           For an institutionalized spouse as defined in 42 U.S.C. 1396r-5(h), available resources shall be determined in accordance with 42 U.S.C. 1396r-5(c), except as specified in Paragraph (m) of this Rule.

(k)  For an institutionalized individual, the availability of resources are determined in accordance with 42 U.S.C. 1396r-5. Resources of the community spouse are not counted for the institutionalized spouse when:

(1)           Resources of the community spouse cannot be determined or cannot be made available to the institutionalized spouse because the community spouse cannot be located; or

(2)           The couple has been continuously separated for 12 months at the time the institutionalized spouse enters the institution.

 

History Note:        Authority G.S. 108A-54; 108A-55; S.L. 1983, c. 1116; 42 U.S.C. 1396r-5; 42 U.S.C. 1396a(a)(17); 42 U.S.C. 1396a(a)(51); 42 C.F.R. 435.602; 42 C.F.R. 435.711; 42 C.F.R. 435.712; 42 C.F.R. 435.723; 42 C.F.R. 435.734; 42 C.F.R. 435.821; 42 C.F.R. 435.822; 42 C.F.R. 435.823; 42 C.F.R. 435.845; 45 C.F.R. 233.20; 45 C.F.R. 233.51; Deficit Reduction Act of 1984 (P.L. 98-369), Section 2373; Correll v. DSS/DMA/DHR, No. 406PA91 (North Carolina Supreme Court); Schweiker v. Gray Panthers, 453 U.S. 34, 101 S.Ct. 2633, 69 L. Ed.2d 460 (1981);

Eff. September 1, 1984;

Amended Eff. January 1, 1995; November 1, 1994; September 1, 1993; April 1, 1993;

Temporary Amendment Eff. September 13, 1999;

Temporary Amendment Expired June 27, 2000;

Temporary Amendment Eff. September 12, 2000;

Amended Eff. August 1, 2002;

Transferred from 10A NCAC 21B .0403 Eff. May 1, 2012.

 

10A NCAC 23E .0208       INCOME

(a)  Income that is actually available and that which the client or someone acting in his behalf can legally make available for support and maintenance shall be counted as income.

(b)  Only income actually available or predicted to be available to the budget unit for the certification period for which eligibility is being determined shall be counted as income.

(c)  For aged, blind, and disabled cases allowable disregards from income are based on Title XVI of the Social Security Act.

(d)  Deductions subtracted after disregards are:

(1)           Child or incapacitated adult care not to exceed one hundred and seventy-five dollars ($175.00) per child over two years of age or adult or two hundred dollars ($200.00) per child under two years of age for Family and Children's related cases.

(2)           A standard deduction of ninety dollars ($90.00) from the total earned income of each budget unit member for Family and Children's related cases.

(3)           For aged, blind, and disabled cases allowable deductions from income are based on Title XVI of the Social Security Act.

(e)  Except for M-PW wages, wage deductions and work-related expenses shall be calculated by converting the average amount per pay period into a monthly amount:

(1)           If paid weekly, multiply by 4.3.

(2)           If paid bi-weekly, multiply by 2.15.

(3)           If paid semi-monthly, multiply by 2.

(4)           If paid monthly, use the monthly gross.

(5)           If salaried, and contract renewed annually, divide annual income etc. by 12.

(f)  For M-PW cases, the budget unit's actual income for the calendar month of eligibility shall be verified.

 

History Note:        Authority G.S. 108A-25(b); 42 C.F.R. 435.121; 42 C.F.R. 435.401; 42 C.F.R. 435.603; 42 C.F.R. 435.731; 42 C.F.R. 435.732; 42 C.F.R. 435.734; 42 C.F.R. 435.812; 42 C.F.R. 435.831; 45 C.F.R. 435.845; 45 C.F.R. 435.851; 45 C.F.R. 233.20; 45 C.F.R. 233.51;

Eff. September 1, 1984;

Amended Eff. January 1, 1995; August 1, 1990; March 1, 1986;

Temporary Amendment Eff. August 22, 1996;

Amended Eff. August 1, 1998;

Transferred from 10A NCAC 21B .0404 Eff. May 1, 2012.

 

10A NCAC 23E .0209       DEDUCTIBLE

(a)  Deductible shall apply to a client in the following arrangements:

(1)           In the community, in private living quarters; or

(2)           In a residential group facility; or

(3)           In a long term care living arrangement when the client:

(A)          Has enough income monthly to pay the Medicaid reimbursement rate for 31 days, but does not have enough income to pay the private rate plus all other anticipated medical costs; or

(B)          Is under a sanction due to a transfer of resources as specified in 10A NCAC 21B .0311; or

(C)          Does not yet have documented prior approval for Medicaid payment of nursing home care; or

(D)          Resided in a newly certified facility in the facility's month of certification; or

(E)           Chooses to remain in a decertified facility beyond the last date of Medicaid payment; or

(F)           Is under a Veterans Administration (VA) contract for payment of cost of care in the nursing home.

(b)  The client or his representative shall be responsible for providing bills, receipts, insurance benefit statements or Medicare EOB to establish incurred medical expenses and his responsibility for payment.  If the client has no representative and he is physically or mentally incapable of accepting this responsibility, the county shall assist him.

(c)  Expenses shall be applied to the deductible when they meet the following criteria:

(1)           The expenses are for medical care or service recognized under state or federal tax law;

(2)           The are incurred by a budget unit member;

(3)           They are incurred:

(A)          During the certification period for which eligibility is being determined and the requirements of Paragraph (d) of this Rule are met; or

(B)          Prior to the certification period and the requirements of Paragraph (e) of this Rule are met.

(d)  Medical expenses incurred during the certification period shall be applied to the deductible if the requirements in Paragraph (c) of this Rule are met and:

(1)           The expenses are not subject to payment by any third party including insurance, government agency or program except when such program is entirely funded by state or local government funds, or private source; or

(2)           The private insurance has not paid such expenses by the end of the application time standard; or

(3)           For certified cases, the insurance has not paid by the time that incurred expenses equal the deductible amount; or

(4)           The third party has paid and the client is responsible for a portion of the charges.

(e)  The unpaid balance of a Medical expense incurred prior to the certification period shall be applied to the deductible if the requirements in Paragraph (c) of this Rule are met and:

(1)           The medical expense was:

(A)          Incurred within 24 months immediately prior to:

(i)            The month of application for prospective or retroactive certification period or both; or

(ii)           The first month of any subsequent certification period; or

(B)          Incurred prior to the period described in Subparagraph (e)(1)(A) of this Rule; and a payment was made on the bill during that period; and

(2)           The medical expense:

(A)          Is a current liability;

(B)          Has not been applied to a previously met deductible; and

(C)          Insurance has paid any amount of the expense covered by the insurance.

(f)  Incurred medical expenses shall be applied to the deductible in chronological order of charges except that:

(1)           If medical expenses for Medicaid covered services and non-covered services occur on the same date, apply charges for non-covered services first; and

(2)           If both hospital and other covered medical services are incurred on the same date, apply hospital charges first; and

(3)           If a portion of charges is still owed after insurance payment has been made for lump sum charges, compute incurred daily expense to be applied to the deductible as follows:

(A)          Determine average daily charge excluding discharge date from hospitals; and

(B)          Determine average daily insurance payment for the same number of days; and

(C)          Subtract average daily insurance payment from the average daily charge to establish client's daily responsibility.

(g)  Eligibility shall begin on the day that incurred medical expenses reduce the deductible to $0, except that the client is financially liable for the portion of medical expenses incurred on the first day of eligibility that were applied to reduce the deductible to $0.  If hospital charges were incurred on the first day of eligibility, notice of the amount of those charges applied to meet the deductible shall be sent to the hospital for deduction on the hospital's bill to Medicaid.

(h)  The receipt of proof of medical expenses and other verification shall be documented in the case record.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.732; 42 C.F.R. 435.831; Alexander v. Flaherty, U.S.D.C., W.D.N.C., File Number C-C-74-483; Alexander v. Flaherty Consent Order filed February 14, 1992;

Eff. September 1, 1984;

Amended Eff. June 1, 1994; September 1, 1993; April 1, 1993; August 1, 1990;

Transferred from 10A NCAC 21B .0406 Eff. May 1, 2012.

 

10a NCAC 23E .0210       PATIENT LIABILITY

(a)  Patient liability shall apply to clients who live in facilities for skilled nursing, intermediate nursing, intermediate nursing for mental retardation or other medical institutions.

(b)  The client's patient liability for cost of care shall be computed as a monthly amount after deducting the following from his total income:

(1)           An amount for his personal needs as established under Rule .0204 of this Section;

(2)           Income given to the community spouse to provide him a total monthly income from all sources, equal to the "minimum monthly maintenance needs allowance" as defined in 42 U.S.C. 1396r-5(d)(3)(A)(i);

(3)           Income given to family members described in 42 U.S.C. 1396r-5(d)(1), to provide each, from all sources of income, a total monthly income equal to:

(A)          One-third of the amount established under 42 U.S.C. 1396r-5(d)(3)(A)(i); or

(B)          Where there is no community spouse, an amount for the number of dependents, based on the income level for the corresponding budget unit number, as approved by the NC General Assembly and stated in the Appropriations Act for categorically and medically needy classifications;

(4)           The income maintenance level provided by statute for a single individual in a private living arrangement with no spouse or dependents at home, for whom the physician of record has provided a written statement that the required treatment is such that the patient is expected to return home within six months, shall be allowed;

(5)           An amount for unmet medical needs as determined under Paragraph (f) of this Rule.

(c)  Patient liability shall apply to institutional charges incurred from the date of admission or the first day of the month as appropriate and shall not be prorated by days if the client lives in more than one institution during the month.

(d)  The county department of social services shall notify the client, the institution and the state of the amount of the monthly liability and any changes or adjustments.

(e)  When the patient liability as calculated in Paragraph (b) of this Rule exceeds the Medicaid reimbursement rate for the institution for a 31 day month:

(1)           The patient liability shall be the institution's Medicaid reimbursement rate for a 31 day month;

(2)           The client shall be placed on a deductible determined in accordance with Federal regulations and Rules .0208 and .0209 of this Section and 10A NCAC 23G .0101.

(f)  The amount deducted from income for unmet medical needs shall be determined as follows:

(1)           Unmet medical needs shall be the costs of:

(A)          Medical care covered by the program but that exceeds limits on coverage of that care and that is not subject to payment by a third party;

(B)          Medical care recognized under State and Federal tax law that is not covered by the program and that is not subject to payment by a third party; and

(C)          Medicare and other health insurance premiums, deductibles, or coinsurance charges that are not subject to payment by a third party.

(2)           The amount of unmet medical needs deducted from the patient's monthly income shall be limited to monthly charges for Medicare and other health insurance premiums.

(3)           The actual amount of incurred costs which are the patient's responsibility shall be deducted when reported from the patient's liability for one or more months.

(4)           Incurred costs shall be reported by the end of the six month Medicaid certification period following the certification period in which they were incurred.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.732; 42 C.F.R. 435.733; 42 C.F.R. 435.831;

42 C.F.R. 435.832; 42 U.S.C. 1396r-5;

Eff. September 1, 1984;

Amended Eff. September 1, 1994; March 1, 1991; August 1, 1990; March 1, 1990;

Transferred from 10A NCAC 21B .0407 Eff. May 1, 2012.

 

10A NCAC 23E .0211       ALIEN SPONSOR DEEMING

(a)  For purposes of this Rule, a sponsored alien is an alien lawfully admitted for permanent residence sponsored by an individual who has signed an Affidavit of Support required by the Bureau of Citizenship and Immigration Services.

(b)  For purposes of this Rule, a sponsor is a person who signed an Affidavit of Support on behalf of an alien as a condition of the alien's entry or admission to the United States.  The sponsor is financially responsible for the alien so the sponsor’s income must be counted in determining an alien's eligibility for medical assistance.

(c)  An indigent alien is exempt from Paragraph (b) of this Rule if the sum of Subparagraphs (1), (2), and (3) of this Paragraph does not exceed 130 percent of the poverty income guidelines.

(1)           The sum of the sponsored alien’s own income;

(2)           The cash contributions of the sponsor and others; and

(3)           The value of any in-kind assistance the sponsor and others provide the alien.

(d)  The countable income of a sponsor is determined in accordance with Rules .0203 and .0208 of this Section. Rule .0206 of this Section applies for situations in which the sponsor is the spouse or a parent.

(e)  The countable resources of a sponsor are determined in accordance with 10A NCAC 21B .0311 and Rule .0207 of this Section.

(f)  Third party verification of the following is required for:

(1)           sponsorship;

(2)           a sponsor's income; and

(3)           a sponsor's resources. 

The application shall be denied if verification is not received by the processing deadline.

 

History Note:        Authority G.S. 108A-25(b); 108A-54; 108A-55; P.L. 104-208; P.L. 105-33;

Temporary Adoption Eff. July 3, 2003;

Eff. March 1, 2004;

Transferred from 10A NCAC 21B .0410 Eff. May 1, 2012.

 

 

 

subchapter 23f – reserveD for future codification

 

 

`subchapter 23g – medicaid certification, correction of eligibility and redetermination of eligibility

 

section .0100 – medicaid certification

 

10A NCAC 23G .0101       CERTIFICATION AND AUTHORIZATION

(a)  Certification.

(1)           Certification periods shall be for:

(A)          One, two or three months if a medical service covered by the state's program was received in the three months prior to the month of application and the client would have been eligible had he applied; or

(B)          Not more than four months for AFDC cases terminated due to child care; or

(C)          Six months for medically needy clients, clients in long term care, with income other than or in addition to SSI, Family and Children's cases and children in county custody or for whom the county has placement responsibility, and categorically needy aged, blind or disabled clients who have deductibles or unstable incomes; or

(D)          Twelve months for categorically needy aged, blind or disabled clients who are in a private living arrangement and have no deductible and whose incomes are stable, clients who are in long term care and have no income other than SSI and children in county custody or for whom the county has placement responsibility who have no deductible and who have stable income; or

(E)           Not more than six months for AFDC cases terminated for the increased earnings or hours of employment; or

(F)           Twelve months for categorically needy clients receiving Special Assistance for the Blind; or

(G)          Twelve months for M-IC cases and children who are born to Medicaid eligible women as described in 10A NCAC 23D .0101(6) or through month of next birthday, whichever is earlier; or

(H)          A lesser number of months if the client dies before the application is completed or if the client is a budget unit member of another case and the months remaining in the certification period for that case are less than six or twelve months as stated in (a)(1)(C) or (D) of this Rule.

(I)            Begin M-PW certification with first month of M-PW coverage and end on the last day of month in which falls the 60th day after the termination of pregnancy.

(2)           Certification periods shall begin:

(A)          With the first month of retroactive medical need except that if the months are not consecutive, each month is a separate certification period; or

(B)          With the month of application except that if application is made in anticipation of a future medical need within the application processing period, the certification begins with the month of medical need; and

(C)          On the first day of the month of certification as stated in (a)(2)(A) and (B) of this Rule.

(3)           Certification is established when a client meets all conditions of eligibility for the program except that he must incur medical expenses equal to the amount by which his income exceeds the income levels.

(4)           Certification shall be terminated when the client's predicted medical expenses not subject to payment by a third party indicate that he cannot meet the amount of his deductible.

(5)           A twelve month certification period shall be adjusted to two six month periods when a change in the client's situation results in his having a deductible or his income becomes unstable.

(6)           Certification periods shall run consecutively unless the client's case is terminated and he reapplies at a later date.  Certification periods shall not overlap except that months included in a previous application which was denied, may be included as retroactive months in a new application.

(b)  Authorization.

(1)           Eligibility shall be authorized when a client meets all conditions of eligibility, including meeting a deductible if one is required.

(2)           The period authorized shall be the portion of the certification period for which all conditions of eligibility are met.

(3)           The beginning and ending dates of the authorization period are stated in 10A NCAC 21B .0204.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.112; 42 C.F.R. 435.914;

Eff. September 1, 1984;

Amended Eff. March 1, 1993; August 1, 1990;

Transferred from 10A NCAC 21B .0405 Eff. May 1, 2012.

SECTION .0200 – correction of erroneous eligibility

 

10A NCAC 23G .0201       GENERAL

(a)  The county department of social services shall correct prior actions according to Rules .0202 and .0203 in this Section when it is discovered that prior actions were in error, or the recipient's circumstances have changed.

(b)  Information leading to corrections may be reported by the recipient, medical providers, state agencies, or any other source with knowledge about the recipient's circumstances.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 431.246; 42 C.F.R. 435.916;

Eff. September 1, 1984;

Amended Eff. June 1, 1990;

Transferred from 10A NCAC 21A .0601 Eff. May 1, 2012.

 

10a NCAC 23G .0202       CORRECTIVE ACTIONS

(a)  Corrections in an applicant's or recipient's case shall be made by the county department of social services when:

(1)           An individual was discouraged from filing an application; or

(2)           An appeal or court decision overturns an earlier adverse decision; or

(3)           The certification periods of financially responsible persons need to be adjusted to coincide; or

(4)           Information received from any source is verified and is found to change the amount of the recipient's deductible, patient liability, authorized period or otherwise affect the recipient's eligibility status; or

(5)           Additional medical bills or verified medical expenses establish an earlier Medicaid effective date; or

(6)           The agency made an administrative error due to:

(A)          Assistance was terminated or denied in error; or

(B)          Failure to act properly on information received; or

(C)          Incorrect determination of the authorization period, Medicaid effective date, or erroneous data entry; or

(7)           Monitoring under application processing requirements determines an application was denied, withdrawn or a person was discouraged from applying for assistance without following the requirements in Alexander v. Burton U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002.

(8)           The Medicaid Eligibility Section determines the county failed to follow federal or state regulations to authorize eligibility or follow requirements in this Chapter.

(b)  Corrections in an applicant's or recipient's case shall be made by the Division of Medical Assistance when:

(1)           Information is received from county departments of social services, medical providers, public, clients or Division of Medical Assistance staff showing that a terminated case has errors in the Medicaid eligibility segments, Buy-In effective date, eligible case members, CAP or HMO indicators and effective dates or other data that is causing valid claims to be denied; or

(2)           The county department of social services refuses to take required corrective actions; or

(3)           An audit report from State auditors hired by the county departments of social services shows verified errors in the Medicaid eligibility history or recipient identification number.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 431.246; 42 C.F.R. 435.904; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Eff. June 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0602 Eff. May 1, 2012.

 

10A NCAC 23G .0203       TIME LIMITS FOR CORRECTIONS

(a)  The county department of social services and Division of Medical Assistance shall make corrections required by Rule .0202 of this Section within 30 days after discovery of the need for action unless good cause exists for failure to act timely.

(b)  Good cause is limited to:

(1)           The need to verify other conditions of eligibility before authorizing eligibility; or

(2)           The county department of social services is unable to locate the applicant or recipient; or

(3)           The county department of social services disagrees with a decision requiring corrective action and has requested administrative review by the Medicaid Eligibility Section;

(c)  To receive state and federal financial participation in any benefits authorized retroactively by corrective actions, the effective date of the correction must correspond with the date assistance would have been effective but may be no earlier than the following dates:

(1)           Retroactive to the date ordered by the appeal or court decision if all eligibility conditions are met, including any legal retroactive coverage period associated with the adverse action; or

(2)           Retroactive to the date that all requirements of eligibility are met but no earlier than the 12th month immediately preceding the month the change is reported or the administrative error was discovered; or

(3)           Retroactive to the date required for corrective action due to errors cited from monitoring under application processing standards in 10A NCAC 23C .0202.

(d)  If the change is adverse to the recipient, it shall be effective with the first calendar month following expiration of the 10 work day advance notice period.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 431.246; 42 C.F.R. 431.250; 42 C.F.R. 435.904; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;

Eff. June 1, 1990;

Temporary Amendment Eff. March 1, 2003;

Amended Eff. August 1, 2004;

Transferred from 10A NCAC 21A .0603 Eff. May 1, 2012.

 

10A NCAC 23G .0204       RESPONSIBILITY FOR ERRORS

(a)  The Division of Medical Assistance shall be financially responsible for the erroneous issuance of benefits and Medicaid claims payments when:

(1)           Policy interpretations given by Division of Medical Assistance or its agents are erroneous and that is the sole cause of any erroneous benefits or payments; or

(2)           Information Services operations staff fail to manually remove Medicaid ID cards from outgoing mail subsequent to the county DSS's timely authorization of a termination or reduction in benefits; or

(3)           A systems failure at the state computer center occurs on the last cutoff date of the month preventing the county DSS from data entering case terminations or adverse actions; or

(4)           Any other failure or error attributable solely to the state occurs.

(b)  The county department of social services shall be financially responsible for the erroneous issuance of benefits and Medicaid claims payments when it:

(1)           Authorizes retroactive eligibility outside the dates permitted by regulations or Rule .0203 of this Section; or

(2)           Fails to send required notices of patient liability or deductible balance to medical providers; or

(3)           Fails to end-date special coverage indicators such as CAP, or HMO in the state eligibility information system; or

(4)           Enters an authorization date in the eligibility system that is earlier than the determined date of eligibility; or

(5)           Fails to determine the availability of or fails to data enter third-party resource information in the state eligibility information system; or

(6)           Terminates a case or individual after the Medicaid ID card has been issued; or

(7)           Issues a county-typed Medicaid ID card that has erroneous dates of eligibility; or

(8)           Fails to initiate application for Medicare Part B coverage for recipients who are eligible, but refuse or are unable to apply for themselves; or

(9)           Takes any other action that requires payment of Medicaid claims for an ineligible individual, for ineligible dates or in an amount that includes a recipient's liability and for which the state cannot claim federal participation.

(c)  The amounts to be charged back to the county department of social services for erroneous payments of claims shall be the state and federal shares of the erroneous payment, not to exceed the lesser of the amount of actual error or claims payment.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 433.32; 42 C.F.R. 435.904;

Eff. June 1, 1990;

Amended Eff. May 1, 1992;

Transferred from 10A NCAC 21A .0604 Eff. May 1, 2012.

 

SECTION .0300 – REDETERMINATION of eligibility and change in situation

 

10A NCAC 23G .0301       TIME AND CONTENT

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.916;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0501 Eff. May 1, 2012;

Expired Eff. August 1, 2016 pursuant to G.S. 150B-21.3A.

 

10A NCAC 23G .0302       INTERVIEW

A redetermination interview shall be conducted with the client or his representative in either the client's place of residence or the county agency office.  During the interview, all eligibility requirements, rights and responsibilities and referrals for other agency services are explained.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.916;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0502 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10a NCAC 23G .0303       RECOMMENDATION

Following the interview and verification of conditions of eligibility, a recommendation shall be made for continuation, modification or termination of benefits.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.919;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21B .0503 Eff. May 1, 2012.

 

10A NCAC 23G .0304       CHANGE IN SITUATION

(a)  For Medicaid applications, once the county department of social services learns from any source that there has been a change in the budget unit's situation they shall notify the applicant within five work days of the need to verify the change.  A change in situation includes but not limited to:

(1)           Change of address, or

(2)           Change in living arrangement, or

(3)           Adding or deleting a budget unit member, or

(4)           Increase or decrease in income, or

(5)           Change in reserve, or

(6)           Cessation of disability or blindness, or

(7)           Parent or parents are no longer incapacitated or unemployed, or

(8)           Change in responsible relative, or

(9)           Change in Aid Program Category.

(b)  For an ongoing Medicaid case, once the county department of social services learns from any source that there has been a change in the budget unit's situation they shall review the case promptly and appropriate action shall be completed within 30 calendar days after the agency learns of the change in situation.

(c)  The Medicaid client or his representative shall report any change in situation that might affect eligibility within 10 calendar days to the county department of social services.

 

History Note:        Authority G.S. 108A-54; 42 C.F.R. 435.916;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Temporary Amendment Eff. August 22, 1996;

Amended Eff. August 1, 1998;

Transferred from 10A NCAC 21B .0409 Eff. May 1, 2012.

 

 

 

subchapter 23H – Confidentiality and access to client records

 

SECTION .0100 ‑ General

 

10A NCAC 23H .0101       SCOPE

The rules of this Subchapter protect the client's right to confidentiality.  Non-identifying statistical information, general information about the scope of any programs administered by the agency, and any written policy relevant to the administration of the Medicaid program, are not confidential information.

 

History Note:        Authority G.S. 108A-54; 108A-80;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0401 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

10A NCAC 23H .0102       INFORMATION FROM OTHER AGENCIES

If the agency receives information from another agency or individual, that information shall be treated as any other information generated by the Division of Medical Assistance or the county department of social services, and disclosure thereof will be governed by any condition imposed by the furnishing agency or individual.

 

History Note:        Authority G.S. 108A-54; 108A-80;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0402 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23H .0103       CONFIDENTIALITY

(a)  Except as otherwise provided in these Rules it shall be unlawful for any person to obtain, disclose or use, or to authorize, permit or acquiesce to the use of any list of names or other information concerning any client applying for or receiving Medicaid that may be directly or indirectly derived from the records, files, or communications of the agency, or acquired in the course of performing official duties except for purposes directly connected with the administration of the Medicaid program.

(b)  Whenever federal or state statutes or regulations specifically address confidentiality issues, the agency shall disclose or keep confidential client information in accordance with those federal or state statutes or regulations.

(c)  Whenever there is inconsistency between federal or state statutes or regulations specifically addressing confidentiality issues, the agency shall abide by the statute or regulation which provides more protection for the client.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.302;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0403 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23H .0104       OWNERSHIP OF RECORDS

(a)  All client information contained in any records of the agency is the property of the agency, and employees of the agency shall protect and preserve such information from dissemination except as provided by the rules of this Subchapter.

(b)  Original client records may not be removed from the premises by individuals other than authorized staff of the agency, except by a court order.

(c)  The agency shall be allowed to destroy records in accordance with record retention schedules promulgated by the Division of Archives and History, rules of the Division of Medical Assistance, and state and federal statutes and regulations.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.306;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0404 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10A NCAC 23H .0105       SECURITY OF RECORDS

(a)  The agency shall provide a secure place or places with controlled access for the storage of records.  Only individuals who must access client information in order to carry out duties assigned or approved by the agency shall be authorized access to the storage area or areas.

(b)  Only authorized individuals may remove a record from the storage area or areas and the authorizing individual shall be responsible for the security of the record until it is returned to the storage area or areas.

(c)  The agency shall establish procedures to prevent accidental disclosure of client information from automated data processing systems.

(d)  The director shall assure that all authorized individuals are informed of the confidential nature of client information and shall disseminate written policy to and provide training for all persons with access to client information.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.306;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0405 Eff. May 1, 2012;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016.

 

10a NCAC 23H .0106       LIABILITY OF PERSONS WITH ACCESS

(a)  Failure to comply with the rules in this Subchapter may constitute a misdemeanor and be punishable by fine or imprisonment as provided by North Carolina General Statute 108A-80.

(b)  Individuals employed by the agency and governed by the State Personnel Act are subject to suspension, dismissal or disciplinary action for failure to comply with these Rules.

(c)  Individuals other than employees but including volunteers and students who are agents of the Department of Health and Human Services and who have access to client information shall be liable in the same manner as employees.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.304;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0406 Eff. May 1, 2012.

 

10A NCAC 23H .0107       RIGHT OF ACCESS

(a)  An individual has the right to obtain data about his own case. Upon written or verbal request the client shall be able to review or obtain without charge a copy of the information in his records with the following exceptions:

(1)           Information that the agency is required to keep confidential by state or federal statutes or regulations;

(2)           Confidential information originating from another agency as provided for in Rule .0104 of this Section.

(3)           Information that would breach another individual's right to confidentiality.

(b)  The agency shall provide access as promptly as feasible but not more than five working days after receipt of the request.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.306;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0407 Eff. May 1, 2012.

 

10A NCAC 23H .0108       WITHHOLDING INFORMATION FROM THE CLIENT

(a)  When the director or a delegated representative determines on the basis of the exceptions in Rule .0107 of this Section to withhold information from the client, this reason shall be documented in the client record.

(b)  The director or delegated representative must inform the client that information is being withheld, and upon which of the exceptions specified in Rule .0107 of this Section the decision to withhold the information is based.  If confidential information originating from another agency is being withheld, the client shall be referred to that agency for access to the information.

(c)  When a delegated representative determines to withhold client information, the decision to withhold shall be reviewed by the supervisor of the person making the initial determination.

 

History Note:        Authority G.S. 108A-54; 108A-80;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0408 Eff. May 1, 2012.

 

10A NCAC 23H .0109       PROCEDURE FOR REVIEW OF RECORDS

(a)  The director or his delegated representative shall be present when the client reviews the record.  The director or his delegated representative must document in the client record the review of the record by the client.

(b)  A client may contest the accuracy, completeness or relevancy of the information in his record.  Correction of the contested information, but not the deletion of the original information if it is required to support receipt of state or federal participation, shall be inserted in the record when the director or his delegated representative concurs that such correction is justified.  When the director or his delegated representative does not concur, the client shall be allowed to enter a statement in the record.  Such corrections and statements shall be made a permanent part of the record and shall be disclosed to any recipient of the disputed information.  If a delegated representative decides not to correct contested information, the decision not to correct shall be reviewed by the supervisor of the person making the initial decision.

(c)  Upon written request from the client, his personal representative, including an attorney, may have access to review or obtain without charge, a copy of the information in his record.  The client may permit the personal representative to have access to his entire record or may restrict access to certain portions of the record.  Rules .0107 and .0108 of this Section shall apply.

 

History Note:        Authority G.S. 108A-54; 108A-80;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0409 Eff. May 1, 2012.

 

10A NCAC 23H .0110       CONSENT FOR RELEASE

(a)  As a part of the application process for Medicaid, the client shall be informed of the need for and give consent to release of information necessary to verify statements to establish eligibility.

(b)  No individual shall release any client information which is owned by the Division of Medical Assistance or the county departments of social services, or request the release of information regarding the client from other agencies or individuals without obtaining a signed consent for release of information.  Disclosure without obtaining consent shall be in accordance with Rule .0111 of this Section.

(c)  The consent for release of information shall be on a form provided by the Division of Medical Assistance or shall contain the following:

(1)           Name of the provider and the recipient of the information;

(2)           The extent of information to be released;

(3)           The name and dated signature of the client;

(4)           A statement that the consent is subject to revocation at any time except to the extent that action has been taken in reliance on the consent;

(5)           Length of time the consent is valid.

(d)  The client may alter the form to contain other information which may include but need not be limited to:

(1)           A statement specifying the date, event or condition upon which the consent may expire even if the client does not expressly revoke the consent;

(2)           Specific purpose for the release.

(e)  The following persons may consent to the release of information:

(1)           The client;

(2)           The legal guardian if the client has been judged incompetent;

(3)           The county department of social services if the client is a minor and in the custody of the county department of social services.

(f)  Prior to obtaining a consent for release of information, the delegated representative shall explain the meaning of informed consent.  The client shall be told the following:

(1)           Contents to be released;

(2)           That there is a definite need for the information;

(3)           That the client can give or withhold the consent and the consent is voluntary;

(4)           That there are statutes and regulations protecting the confidentiality of the information.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.304; 42 C.F.R. 431.306;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0410 Eff. May 1, 2012.

 

10A NCAC 23H .0111       DISCLOSURE WITHOUT CLIENT CONSENT

(a)  Client information from the Medicaid record may be disclosed without the consent of the client under the following circumstances:

(1)           To other employees of the county department of social services for purpose of making referrals, supervision, consultation or determination of eligibility;

(2)           To other county departments of social services when the client moves to that county and requests Medicaid;

(3)           Between the county departments of social services and the Division of Medical Assistance for purposes of supervision and reporting.

(b)  Client information may be disclosed without consent to individuals requesting approval to conduct studies of client records, provided such approval is requested in writing and the written request will specify and be approved on the basis of:

(1)           An explanation of how the findings of the study have potential for expanding knowledge and improving professional practices;

(2)           A description of how the study will be conducted and how the findings will be used;

(3)           A presentation of the individual's credentials in the area of investigation;

(4)           A description of how the individual will safeguard the information;

(5)           An assurance that no report will contain the names of individuals or other information that makes individuals identifiable.

(c)  Client information may be disclosed without consent to federal, state, or county employees for the purpose of monitoring, auditing, evaluation, or to facilitate the administration of other state and federal programs, provided that the need for the disclosure of confidential information is justifiable for the purpose and that adequate safeguards are maintained to protect the information from re-disclosure.

(d)  Client information may be disclosed without consent for purposes of complying with other state and federal statutes and regulations and court orders.

(e)  When information is released without the client's consent, the client shall be informed to the extent possible, of the disclosure.  The method of informing the client of the disclosure shall be documented in the appropriate record.

 

History Note:        Authority G.S. 108A-54; 108A-80; 42 C.F.R. 431.306;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0411 Eff. May 1, 2012.

 

10A NCAC 23H .0112       DOCUMENTATION OF CONSENT OR DISCLOSURE

Whenever client information is disclosed in accordance with rules of this Subchapter, the director or delegated representative shall insure that documentation of the disclosure is placed in the appropriate client record.

 

History Note:        Authority G.S. 108A-54; 108A-80;

Eff. September 1, 1984;

Transferred from 10A NCAC 21A .0412 Eff. May 1, 2012.

 

10A NCAC 23H .0113       PERSONS DESIGNATED TO DISCLOSE INFORMATION

Only directors of county departments of social services and their designated representatives may disclose client information in accordance with rules of this Subchapter.

 

History Note:        Authority G.S. 108A-54; 108A-80;

Eff. September 1, 1984;

Amended Eff. August 1, 1990;

Transferred from 10A NCAC 21A .0413 Eff. May 1, 2012.