`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.