SUBCHAPTER 71P - STATE/COUNTY SPECIAL ASSISTANCE FOR ADULTS

 

SECTION .0100 - GENERAL PROVISIONS

 

10A NCAC 71P .0101        SUPERVISION

The Department of Health and Human Services, Division of Aging and Adult Services, Adult Services Section, is responsible for supervising the administration of the State/County Special Assistance Program. The section is located at 693 Palmer Drive, 2101 Mail Service Center, Raleigh, North Carolina, 27699-2101. The office is open during regular business hours.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0102        DEFINITIONS

For purposes of this Chapter are the following definitions:

(1)           "Adult Care Facility" for purposes of this Subchapter shall mean group residential care facilities for persons who cannot remain in their own homes and who reside in facilities licensed by the Department of Health and Human Services defined in the following statutes and rules:

(a)           Adult Care Homes - G.S. 131D-2.1-10, 10A NCAC 13F .0200, and 10A NCAC 13G .0200;

(b)           Facilities for persons with mental illness and developmental disabilities - G.S. 122C-21, 10A NCAC 27G .5601(c)(1) and (3);

(c)           For persons aged less than 18 who are legally blind, facilities licensed pursuant to 10A NCAC 27G .2101.

(d)           Combination Homes in Nursing Facilities - G.S. 131E-101(1) and (1a);

(e)           Combination Facilities in Hospitals - 10A NCAC 13B .1902(6); and

(f)            Hospice Residential Care Facilities - G.S. 131E‑201(5a).

(2)           "Adult Care Facility Rate" shall mean the maximum monthly rate for residents in an Adult Care Facility as established by the General Assembly.

(3)           "Authorized Representative" shall mean a person who is legally authorized or designated in writing by the applicant or recipient to act on his or her behalf.

(4)           "Budget Unit" shall mean, for the purposes of the State/County Special Assistance for the Certain Disabled Program, a spouse or Essential Person who resides with the recipient and whose income, combined with the income of the recipient, is considered in determining the monthly payment.

(5)           "Case Manager" for the State/County Special Assistance In-Home Program shall mean the social work staff member of the County Department who conducts the functional assessment and determines the actual payment amount, pursuant to G.S. 108A-47.1 and to Rule .0306 of this Subchapter.

(6)           "Caseworker" shall mean the staff member of the County Department who evaluates the applicant's eligibility for State/County Special Assistance, processes the application, and reviews the case for continuing eligibility pursuant to the rules in this Subchapter.

(7)           "Change in Situation" shall mean the changes in an applicant's or recipient's circumstances as set forth in 20 C.F.R. 416.708 that could affect his or her eligibility or payment amount.

(8)           "Countable Monthly Income" shall mean the amount of monthly income after applying all allowable deductions pursuant to 20 C.F.R. 416.1102-1104.

(9)           "County Board" shall mean the county board of social services as set forth in G.S. 108A-1 and G.S. 108A-9.

(10)         "County Department" shall mean the county department of social services as set forth in G.S. 108A-12, G.S. 108A-14(a)(3), G.S. 108A-14(b), and G.S. 108A-15.1.

(11)         "Division of Aging and Adult Services" shall mean the Division of Aging as defined in G.S. 143B-181.1.

(12)         "Essential Person" shall mean, for the purposes of the State/County Special Assistance for the Certain Disabled Program, a person who is not a spouse and who is living in the recipient's home, rendering services without which the recipient would not be able to remain in his or her home.

(13)         "Maintenance Amount" shall mean the Adult Care Facility Rate plus the Personal Needs Allowance.

(14)         "Personal Needs Allowance" shall mean, for the purposes of this Subchapter, the monthly sum of money that a recipient of the State/County Special Assistance Program may retain from his or her personal income for clothing and other personal needs and expenses as described in 42 C.F.R. 435.832(c)(1). The monthly Personal Needs Allowance for the State/County Special Assistance Program is established by the General Assembly.

(15)         "State/County Special Assistance Program" is authorized and established by G.S. 108A-25(a)(2) and G.S. 108A-40 through G.S. 108A-47.1. The State/County Special Assistance Program provides to eligible individuals an Optional State Supplementary payment to the federal Supplemental Security Income Program (SSI), pursuant to 42 U.S.C. 1382e and 20 C.F.R. 416.2001

(16)         "State/County Special Assistance for the Certain Disabled Program" is authorized and established by G.S. 108A-41(d), G.S. 108A-42(b), and G.S. 108A-45 for persons in an in-home living arrangement who meet the eligibility criteria set forth in Rule .0805 of this Subchapter.

(17)         "State/County Special Assistance In-Home Program" is authorized and established by G.S. 108A-47.1 for persons living in an in-home living arrangement who meet the eligibility criteria in Rules .0803 and .0804 of this Subchapter. For purposes of this Subchapter, the State/County Special Assistance Program shall also include the State/County Special Assistance In-Home Program unless otherwise noted.

(18)         "Substitute Payee" shall mean an Authorized Representative who is responsible for receiving and disbursing State/County Special Assistance Program payments to meet the recipient's needs.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; June 1, 1990; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0103        STATE/COUNTY SPECIAL ASSISTANCE PROGRAM PROCEDURES

The following general procedures shall be applicable to the State/County Special Assistance Program:

(1)           Notice and hearing rules set forth in 10A NCAC 67A .0200 shall apply to the State/County Special Assistance Program.

(2)           Confidentiality rules set forth in 10A NCAC 69 shall apply to the State/County Special Assistance Program.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

SECTION .0200 - ADULT CARE

 

10A NCAC 71P .0201        MAXIMUM RATES

The County Department may negotiate rates lower than the maximum rates with operators of Adult Care Facilities. Maximum rates are established by the General Assembly and are available on the Department of Health and Human Services website at www.dhhs.nc.gov and in each County Department.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0202        LICENSED FACILITIES

(a)  Adult Care Facilities that accept State/County Special Assistance Program payments from recipients residing in such facilities as set forth in G.S. 108A-41(a) and Rule .0102(1) of this Subchapter shall have signed a civil rights compliance statement and have submitted it to the Division of Aging and Adult Services pursuant to 42 U.S.C. 2000d and 45 C.F.R. 80.2.

(b)  Adult Care Facilities shall be licensed by the Department of Health and Human Services.

(c)  This Rule does not apply to the State/County Special Assistance In-Home Program or to the State/County Special Assistance for the Certain Disabled Program.

 

History Note:        Authority G.S. 108A-40; 108A-41; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

SECTION .0300 - BUDGETING PRINCIPLES

 

10A NCAC 71P .0301        MINIMUM PAYMENT

The minimum State/County Special Assistance Program payment is one dollar ($1.00).

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0302        Recipient IN AN ADULT CARE FACILITY

The monthly State/County Special Assistance Program payment computation shall comply with 42 C.F.R. 435.232(b)(2). The payment shall be computed by:

(1)           Determining the Maintenance Amount, as defined in Rule .0102(13) of this Subchapter;

(2)           Subtracting the recipient's Countable Monthly Income from the Maintenance Amount; and

(3)           Rounding the difference to the nearest dollar.

 

History Note:        Authority G.S. 108A-40; 108A-41; 143B-153; 42 C.F.R. 435.232(b)(2);

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0303        RECIPIENT IN DOMICILIARY CARE WITH SPOUSE AT HOME

10A NCAC 71P .0304        RECIPIENT/DOMICILIARY CARE: SPOUSE/NOT RECEIVING ASSIST.

 

History Note:        Authority G.S. 143B-153;

Eff. January 1, 1983;

Repealed Eff. June 1, 2016.

 

10A NCAC 71P .0305        CERTAIN DISABLED CASES

The minimum payment for Certain Disabled cases is five dollars ($5.00). The following budgeting principles apply:

(1)           An individual applicant/recipient's special assistance payment is computed by allowing one hundred twenty‑seven dollars ($127.00) for maintenance; subtracting net income from needs; and rounding the difference to the nearest dollar.

(2)           If an applicant or recipient has a needy spouse or other essential person residing in his own home, the recipient's special assistance payment shall be computed by allowing one hundred sixty‑five dollars ($165.00) for maintenance; subtracting their combined net income from their needs; and rounding the difference to the nearest dollar.

 

History Note:        Authority G.S. 143B‑153;

Eff. January 1, 1983;

Amended Eff. July 1, 1984;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0306        Recipient IN AN In-home living arrangement

(a)  The State/County Special Assistance In-Home Program maximum payment for recipients living in an in-home living arrangement and not in an Adult Care Facility shall be computed by:

(1)           determining the Maintenance Amount as set forth in Rule .0102(13) of this Subchapter;

(2)           subtracting the recipient's Countable Monthly Income from the Maintenance Amount; and

(3)           rounding the difference to the nearest dollar.

(b)  The County Department Case Manager shall determine the actual State/County Special Assistance In-Home Program payment by conducting a comprehensive functional assessment pursuant to G.S. 108A-47.1(a) and shall include the areas related to health and safety as set forth in 10A NCAC 71A .0208.  The State/County Special Assistance In-Home Program payment may be authorized up to the maximum determined in Paragraph (a) of this Rule.

 

History Note:        Authority G.S. 108A-47; 108A-47.1; 143B‑153;

Eff. June 1, 2016.

 

SECTION .0400 - MIXED BUDGETING: WHEN OTHER BUDGET MEMBERS ARE RECIPIENTS

 

10A NCAC 71P .0401        MINIMUM PAYMENT

10A NCAC 71P .0402        RECIPIENT/DOMICILIARY CARE: SPOUSE/CHILDREN RECEIVING AFDC

10A NCAC 71P .0403        RECIPIENT/DOMICILIARY CARE: SPOUSE/CHILDREN RECV'G AFDC-MA

10A NCAC 71P .0404        RECIPIENT/DOMICILIARY CARE: SPOUSE/RECV'G MEDICAL ASSIST.

10A NCAC 71P .0405        RECIPIENT/SPOUSE BOTH RECEIVING SPECIAL ASSISTANCE

10A NCAC 71P .0406        RECIPIENT/DOMICILIARY CARE: SPOUSE: NURSING/INTERMED. FAC.

 

History Note:        Authority G.S. 143B-153;

Eff. January 1, 1983;

Repealed Eff. June 1, 2016.

 

SECTION .0500 - PAYMENT PROCEDURES

 

10A NCAC 71P .0501        SUBSTITUTE PAYEE

(a)  The recipient shall be payee for his or her own State/County Special Assistance Program payment unless the recipient or his or her Authorized Representative designates an Authorized Representative to serve as a Substitute Payee.

(b)  The administrator or a staff member of an Adult Care Facility shall not act as Substitute Payee for State/County Special Assistance Program payments for recipients who reside at the Adult Care Facility that employs such administrator or staff member, as set forth in 10A NCAC 13F .1103.

(c)  The director of the County Department may invoke the procedures set forth in G.S. 108A-37 when he or she determines that a recipient is unwilling or unable to manage his or her State/County Special Assistance Program payments to the extent that deprivation or hazard to himself or herself or others results.

(d)  State/County Special Assistance Program payments shall not be issued to persons or entities designated in G.S. 108A-47.

 

History Note:        Authority G.S. 108A-25; 108A-37; 108A-40; 108A-47; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0502        PAYMENT AUTHORIZATION

(a)  State/County Special Assistance Program payments for any recipient shall not be authorized prior to the month of application.

(b)  If SSI approval is pending at the time of application, the State/County Special Assistance Program payment may be authorized retroactive to the month SSI was approved if the recipient was in an Adult Care Facility and had applied for the State/County Special Assistance Program during the month that such assistance was approved.

(c)  If a recipient enters an Adult Care Facility or meets the North Carolina residency requirement for the State/County Special Assistance Program after the first day of the month and all other eligibility criteria are met, the recipient shall be eligible only for a partial payment for that month from the date of entry or the date the recipient meets the residency requirement to the end of the month. The payment shall be computed without considering income.

(d)  If a recipient's level of care is determined to no longer be Adult Care Facility level and a bed is not readily available under the Medicaid Program, the State/County Special Assistance Program payments shall continue until a bed at the appropriate level of care is available for the recipient.

 

History Note:        Authority G.S. 108A-40; 108A-41(b); 143B-153;

Eff. January 1, 1983;

Amended Eff. July 1, 1988;

Temporary Amendment Eff. October 28, 1997;

Amended Eff. June 1, 2016; April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0503        CORRECTION OF UNDERPAYMENTS

Retroactive adjustment for any underpayment that results from administrative errors shall be made, but the correction shall not be made for any underpayment that was made more than 12 months before the corrective action is taken by the eligibility specialist.

 

History Note:        Authority G.S. 143B‑153;

Eff. January 1, 1983;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0504        CORRECTION OF OVERPAYMENTS

(a)  An overpayment caused by an error by a Department of Health and Human Services staff member in interpreting program regulations shall be charged to the State.

(b)  If an overpayment is caused by failure of the recipient or his or her Authorized Representative to report a Change in Situation as set forth in Rule .0602(b)(5)(C) of this Subchapter, and if fraud is not suspected, the County Department shall direct the recipient to refund the overpayment.

(1)           If the recipient refuses to refund the overpayment, the State/County Special Assistance Program monthly payment may be reduced up to 10 percent if he or she has:

(A)          disregarded earned income determined pursuant to 20 U.S.C 416.1112; or

(B)          countable resources, as defined in Rule .0904 of this Subchapter, greater than the amount of the overpayment.

(2)           If the recipient has no disregarded earned income or excess resources, the recipient shall be asked to agree in writing to repay the amount of the overpayment to the State and County Department if he or she acquires income or resources greater than the amount of the overpayment while he or she is a recipient of the State/County Special Assistance Program.

(c)  An overpayment caused by an error by a County Department staff member shall be charged to the County Department.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0505        ISSUANCE OF PAYMENTS

(a)  The County Department shall authorize State/County Special Assistance Program payments based on the eligibility determination decision of the Caseworker.

(b)  All payments shall be issued by the electronic method requested by the recipient or Substitute Payee.

(c)  Payments may be replaced up to 12 months after initial issuance.

 

History Note:        Authority G.S. 108A-40; 108A-43; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0506        RECEIPT AND USE OF CHECKS

 

History Note:        Authority G.S. 143B-153;

Eff. January 1, 1983;

Repealed Eff. June 1, 2016.

 

10A NCAC 71P .0507        LOST: STOLEN AND FORGED CHECKS

 

History Note:        Authority G.S. 143B-153; 108A-40;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; May 1, 1988;

Expired Eff. June 1, 2017 pursuant to G.S. 150B-21.3A.

 

10A NCAC 71P .0508        FRAUD

(a)  Definitions: Fraud and Misrepresentation.

(1)           For the purposes of this Subchapter, an applicant or recipient engages in fraud when he or she willfully and knowingly with the intent to deceive:

(A)          makes a false statement or misrepresentation;

(B)          fails to disclose a material fact; or

(C)          does not report any Change in Situation that affects the amount of the State/County Special Assistance Program payment; and as a result obtains or continues to receive a payment.

(2)           Misrepresentation:

(A)          Intentional misrepresentation: An applicant or recipient engages in intentional misrepresentation when he or she gives incorrect or misleading information in response to either oral or written questions which the applicant or recipient knows is incorrect, misleading, or incomplete.

(B)          Unintentional misrepresentation: An applicant or recipient engages in unintentional misrepresentation when he or she gives incomplete, incorrect, or misleading information because he or she does not understand the eligibility requirements or his or her responsibility to provide the County Department with required information and there is no proof that the applicant or recipient acted willfully and knowingly to obtain more State/County Special Assistance Program payments than those to which he or she was entitled.

(b)  Fraud Prevention.

(1)           When interviewing an applicant or recipient as set forth in Rules .0601 and .0602 of this Subchapter, the Caseworker shall:

(A)          Obtain the correct social security number for the applicant or recipient;

(B)          explain the obligation of the applicant, recipient, or Authorized Representative to report any Change in Situation within five calendar days after they occur;

(C)          inform the applicant, recipient, or Authorized Representative of the consequences of failing to report a Change in Situation, stressing the penalties for fraud and misrepresentation;

(D)          provide the applicant, recipient, or Authorized Representative with a copy of the pamphlet entitled Public Assistance Fraud, available at all County Departments, and explain to the applicant, recipient, or Authorized Representative the meaning of fraud as described in this Rule;

(E)           inform the applicant, recipient, or Authorized Representative how to report a Change in Situation; and

(F)           ask the recipient or Authorized Representative about any Change in Situation since the application or last review.

(2)           Documentation and Verification. The Caseworker shall verify and document in detail the information given during the interview.

(c)  Detection. The Caseworker shall check online verification systems as designated and made available by the State to verify personal eligibility requirements of the applicant or recipient. If information that could affect an applicant's or recipient's eligibility or payment amount is received from any source, the County Department shall investigate.

(d)  Investigation. County Department responsibilities.

(1)           When a County Department discovers evidence that an applicant or recipient obtained State/County Special Assistance Program payments to which he or she was not entitled or received an overpayment, the Caseworker shall assess whether the County Department determined eligibility and documented eligibility information according to the rules set forth in this Subchapter. The County Department shall obtain and document all evidence necessary to determine whether the applicant or recipient intended to defraud and whether the overpayment was due to the applicant's or recipient's intentional or unintentional misrepresentation.

(2)           The County Department director or his or her designee shall review each case after receiving the Caseworker's evaluation. If there is sufficient evidence to suspect fraud, the director shall refer the case for a decision to the County Board or make the decision if the County Board has designated that he or she do so.

(3)           If the director of the County Department determines that the case should go before the County Board, a summary shall be prepared which contains:

(A)          the name of the applicant or recipient and his or her date of birth and social security number;

(B)          a description of the suspected fraudulent act;

(C)          a description of the evidence substantiating the applicant's or recipient's intent to defraud;

(D)          a description of the evidence substantiating the amount of the overpayment; and

(E)           background information, such as the applicant's or recipient's current situation, educational background, and competency.

(e)  County Board of Social Services Responsibilities.

(1)           The County Board or its designee shall review the suspected fraud case to determine if there is a basis for suspected fraud and determine the appropriate course of action to take. While fraud may be suspected, the County Board may decide that the applicant's or recipient's circumstances preclude prosecution and/or repayment. The County Board shall determine if the applicant or recipient:

(A)          willfully and knowingly misstated or provided incorrect or misleading information in response to oral or written questions;

(B)          willfully and knowingly failed to report a Change in Situation affecting eligibility for the State/County Special Assistance Program or the amount of payment; or

(C)          willfully and knowingly failed to report the receipt of payments to which the recipient knew he or she was not entitled.

(2)           If the County Board determines that an applicant or recipient engaged in intentional misrepresentation, it shall direct the County Department to pursue one or more of the following:

(A)          Administrative action:

(i)            the recipient's State/County Special Assistance Program payment shall be reduced up to 10 percent of the payment;

(ii)           the recipient's voluntary agreement that his or her State/County Special Assistance Program payment may be reduced; or

(iii)          the recipient will voluntarily return the State/County Special Assistance Program overpayment in part or in full;

(B)          Civil court action;

(C)          Criminal court action;

(D)          Take no action for unusual or hardship circumstances, as set forth in 20 C.F.R. 404.508(a) and 20 C.F.R. 416.553(a), in which a payment reduction would deprive the recipient of necessary income for:

(i)            fixed living expenses, such as paying for food and shelter including payment to the Adult Care Facility;

(ii)           medical, hospitalization, and other such expenses;

(iii)          expenses for the support of others for whom the individual is legally responsible; or

(iv)          other expenses which are reasonable as part of the recipient's standard of living.

(f)  County Department Follow‑Up.

(1)           Administration action:

(A)          Involuntary payment reduction. Payment reduction shall be required only if the recipient has disregarded earned income determined as set forth in 20 C.F.R. 416.1112 or resources greater than the overpayment amount. The amount of the payment reduction shall not exceed the amount available as disregarded earned income or resources greater than the overpayment amount. If the recipient has no resources, the County Board shall direct the County Department to require the recipient to sign a statement that he or she will repay the overpayment if he or she acquires resources in the future, pursuant to Rule .0504(b) of this Subchapter.

(B)          Voluntary State/County Special Assistance Program payment reduction and voluntary recipient refund. The amount of the voluntary payment reduction shall not exceed the amount available as disregarded earned income or resources greater than the overpayment amount.

(2)           Criminal court action. The County Department shall assist the prosecutor by:

(A)          providing a clear and concise summary of the suspected fraud case;

(B)          compiling information gathered during the investigation;

(C)          explaining the specific eligibility factors involved in the case;

(D)          explaining in detail how the overpayment amount was computed and the time requirements on the County Department's actions, such as the notice requirement as set forth in Rule .0705 of this Subchapter and the five calendar day Change in Situation reporting requirement as set forth in Rule .0602(5)(c) of this Subchapter; and

(E)           if necessary, appearing as a witness.

(3)           Regardless what the County Board or its designee decides or what action is taken by the court, the County Department shall continue to provide State/County Special Assistance Program payments. The applicant or recipient shall be notified in writing within one business day of any action taken in the case. If the applicant or recipient remains eligible, the State/County Special Assistance Program payment shall not be terminated solely because fraud is suspected.

(4)           If the County Board or its designee suspects fraud, the County Department's findings and action shall be reported to the Adult Services Section of the Division of Aging and Adult Services.

(5)           The County Department shall retain all State/County Special Assistance Program documentation, evidence, or summaries in accordance with the Medicaid Program retention requirements found in the Record Retention and Disposition Schedule for Grants published by the Controller's Office of the Department of Health and Human Services on the website at http://www.ncdhhs.gov/control.

 

History Note:        Authority G.S. 108A 25.3; 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; June 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

SECTION .0600 - APPLICATION PROCESS

 

10A NCAC 71P .0601        ACCEPTANCE OF APPLICATION

A County Department shall accept an application for the State/County Special Assistance Program as set forth in this Rule.

(1)           An applicant shall be allowed to apply on the same day the applicant appears at any County Department.

(2)           The applicant shall be informed, orally and in writing, that:

(a)           he or she may apply on the same day he or she appears at any County Department;

(b)           a decision shall be made concerning his or her application within the time standards set forth in Rule .0604 of this Subchapter; and

(c)           the applicant shall receive a written decision from the County Department concerning the application.

(3)           The County Department in the applicant's county of residence shall be responsible for processing the application. For the purpose of submitting an application, the applicant or his or her Authorized Representative may appear at the County Department where he or she currently resides in an Adult Care Facility or at another County Department that is conveniently located for the Authorized Representative. The applicant shall not be required to travel to the county he or she resided in prior to entering an Adult Care Facility.

(4)           The date of the application shall be the date the signed application is received by the County Department; however, if the applicant is a patient of a State mental health facility listed in G.S. 122C-181, the date of application shall be the date the referral from the mental health facility is received by the County Department.

(5)           If an applicant requests to apply for the State/County Special Assistance Program by mail or electronic submission to the County Department, the letter or electronic submission shall be considered a request to apply. A follow-up contact or electronic response shall be sent within three business days after the request is received by the County Department. The follow-up letter or electronic response shall request that the applicant come to the County Department for an interview or contact the County Department so that other arrangements can be made. The County Department's response to the applicant requesting the State/County Special Assistance Program shall specify that if the County Department does not hear from the applicant within 15 calendar days of the date of the follow-up letter or electronic response, the County Department shall deem the request for the State/County Special Assistance Program application to have been withdrawn.

(6)           If an applicant requests to apply for the State County Special Assistance Program by telephone or electronic submission, the applicant or his or her Authorized Representative shall be advised that he or she shall apply in person at the County Department at any time during regular business hours. If the applicant requests a specific time, an application interview appointment shall be scheduled.

(7)           The application form shall:

(a)           consist of questions specifically related to eligibility pursuant to 20 C.F.R. 416.2001(a); 416.2001(b), 416.202, Rules .0804, .0805, and Section .0900 of this Subchapter; and

(b)           contain the applicant's rights and responsibilities set forth in Rule .0602(4) and .0602(5).

(c)           require a signature of the applicant or his or her Authorized Representative that he or she has provided truthful information and that he or she understands his or her rights and responsibilities.

(8)           A blank application form shall be available for public review at each County Department.

(9)           An application for the State/County Special Assistance In-Home Program shall require a comprehensive functional assessment to determine whether the monthly payment amount will be sufficient to both meet the needs of the recipient in the home and help prevent placement in an Adult Care Facility. The comprehensive functional assessment shall be conducted by the Case Manager and shall include the areas related to health and safety as set forth in 10A NCAC 71A .0208.

 

History Note:        Authority G.S. 108A-40; 108A-43; 108A-47.1; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0602        INITIAL Application

(a)  The Caseworker shall explain that eligibility for the State/County Special Assistance Program provides:

(1)           a cash payment; and

(2)           Medicaid as set forth in 42 C.F.R. 435.232 and 10A NCAC 23D .0102(2). Neither 42 U.S.C. 1382e, 20 C.F.R. 416.2001, 42 C.F.R. 435.232, nor 10A NCAC 23D .0102(2) shall apply to the State/County Special Assistance In-Home Program nor to the State/County Special Assistance for the Certain Disabled Program.

(b)  The Caseworker shall explain the eligibility requirements for the State/County Special Assistance Program and the applicant's rights and responsibilities. The Caseworker shall inform the applicant of the following:

(1)           The applicant shall provide the name of collateral sources of information such as landlords, employers, and others who can substantiate or verify the applicant's eligibility information.

(2)           It is the County Department's responsibility to use collateral sources to substantiate or verify information necessary to establish eligibility. Collateral sources of information include knowledgeable individuals, business organizations, public records, and documentary evidence. If the applicant does not wish the County Department to contact such collateral sources, he or she may withdraw the application. If the applicant denies permission for the County Department to contact such collateral sources and does not withdraw his or her application, the application shall be denied.

(3)           The County Department staff shall verify the applicant's residence.

(4)           The applicant has the right to:

(A)          receive the State/County Special Assistance Program payments if he or she is found eligible for such assistance;

(B)          be protected against discrimination on the ground of race, color, or national origin by Title VI of the Civil Rights Act of 1964: if the applicant believes he or she was a victim of such discrimination, he or she may file a civil rights complaint in writing to the United States Department of Health and Human Services, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or by calling (202) 619-0403 (voice) or (202) 619-3257 (TTY). Further information can be found on the U.S. Department of Health and Human Services website "How to File a Civil Rights Complaint" at: http://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process;

(C)          designate a Substitute Payee as set forth in Rule .0501 of this Subchapter;

(D)          have any person or his or her Authorized Representative participate in the application process and receive notices;

(E)           have any information given to the County Department kept in confidence;

(F)           appeal, if:

(i)            his or her State/County Special Assistance Program application is denied;

(ii)           the applicant believes that the payment is incorrect based on the county's interpretation of State regulations; or

(iii)          if the applicant's request for a review of his or her eligibility decision was delayed more than 30 calendar days;

(G)          reapply at any time, if found ineligible; and

(H)          withdraw the application at any time or withdraw from the State/County Special Assistance Program at any time.

(5)           The applicant's responsibilities. The applicant or Authorized Representative shall:

(A)          provide the County Department with the collateral sources from which the County Department can locate and obtain information needed to determine eligibility, including furnishing his or her social security number;

(B)          not provide false statements or withhold information that relates to the applicant's eligibility;

(C)          report to the County Department any Change in Situation, within five calendar days of such change, that may affect his or her eligibility for the State/County Special Assistance Program payment;

(D)          cooperate with the County Department in support of any right of subrogation the State may have pursuant to State or federal law; and

(E)           report within five business days to the County Department the receipt of a payment which the recipient knows to be erroneous, such as two payments for the same month or a payment in the wrong amount. If the recipient does not report such payments, he or she may be required to repay any overpayment.

(c)  The application for the State/County Special Assistance Program shall include:

(1)           the applicant's full name;

(2)           the applicant's address;

(3)           the signature of the applicant or his or her Authorized Representative. The signature shall assure that he or she understands his or her rights and responsibilities as set forth in Rule .0602 of this Subchapter; and

(4)           sufficient information as set forth in Rule .0601(7) of this Subchapter in order for the Caseworker to determine eligibility for the State/County Special Assistance Program. For the State/County Special Assistance In-Home Program, the application shall also include the results of the comprehensive functional assessment that shall include the areas set forth in 10A NCAC 71A .0208.

 

History Note:        Authority G.S. 108A-40; 108A-41(b); 143B-153;

Eff. January 1, 1983;

Temporary Amendment Eff. October 28, 1997;

Amended Eff. June 1, 2016; April 1, 1999.

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0603        ELIGIBILITY DETERMINATION PROCESS

The following steps shall be followed by the County Department in determining eligibility for the State/County Special Assistance Program:

(1)           each eligibility factor as set forth in Rules .0804 and .0805 of this Subchapter shall be reviewed;

(2)           the Caseworker shall verify the applicant's residence in a licensed Adult Care Facility or the Case Manager shall verify the applicant's residence in an in-home living arrangement;

(3)           the applicant shall be asked whether he or she receives SSI benefits. If the applicant's income is less than the Federal Benefit Rate for SSI pursuant to 20 C.F.R. 416.1101, the individual shall also apply for SSI benefits in order to be eligible for the State/County Special Assistance Program. If he or she has not applied for SSI prior to his or her application for the State County Special Assistance Program, he or she shall be asked to apply. The State/County Special Assistance Program application shall not be approved or denied until a decision on the SSI application is received; and

(4)           for applicants of the State/County Special Assistance In-Home Program, the Case Manager shall conduct a comprehensive functional assessment that that shall include the areas set forth in 10A NCAC 71A .0208. This assessment shall determine whether the State/County Special Assistance In-Home Program payment and case management services provided by the Case Manager will be sufficient to meet the needs of the recipient in the home and help prevent placement in an Adult Care Facility. The applicant shall agree to accept case management to be approved for the State/County Special Assistance In-Home Program. The case management services shall be consistent with Individual and Family Adjustment Services pursuant to 10A NCAC 71R .0910(a).

 

History Note:        Authority G.S. 108A-40; 108A-41; 143B-153;

Eff. January 1, 1983;

Temporary Amendment Eff. January 1, 2000;

Amended Eff. June 1, 2016; July 17, 2000;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0604        TIME STANDARD

(a)  Unless otherwise provided in this Rule, complete applications as set forth in Rule .0602(b) and .0602(c) of this Subchapter shall be processed and a notice approving or denying the application stating the effective date of the payment shall be mailed:

(1)           within 45 calendar days from the date the application form is signed for persons aged 65 and older; and

(2)           within 60 calendar days from the date the application form is signed for persons aged less than 65.

(b)  The time standard defined in Paragraph (a) of this Rule shall apply unless a decision for SSI eligibility or disability determination is pending from the Social Security Administration. In the case of a pending SSI application or disability decision, the decision regarding the State/County Special Assistance Program application may be delayed for no more than 12 months.

(c)  If the applicant's eligibility cannot be determined by the beginning of the 12th month after the date of application, the applicant shall be notified that his or her application will be denied unless the SSI decision is received by the end of the 12th month after the date of application.

 

History Note:        Authority G.S. 108A-40; 108A-79; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; June 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0605        RECOMMENDATION

When all information necessary for an eligibility determination has been obtained, the eligibility specialist shall recommend whether to approve or to deny assistance. The recommendation shall be based on reliable, relevant information. If the authority to approve assistance has been delegated by the county board of social services to the county director, the recommendation may be made to the county director. The eligibility staff shall have no authority to approve or reject an application.

 

History Note:        Authority G.S. 108A‑43; 143B‑153;

Eff. January 1, 1983;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0606        DISPOSITION

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

(1)           Authorization of assistance;

(2)           Denial of assistance;

(3)           Voluntary withdrawal of application. Withdrawal shall be by the applicant or his representative and shall be voluntary. The eligibility specialist shall attempt to make sure that the applicant or representative understands the nature of his action and understands that he may reapply at any time.

 

History Note:        Authority G.S. 143B‑153;

Eff. January 1, 1983;

Amended Eff. June 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0607        REPORT OF DISPOSITION

Using the same form used to notify the state office of the processing of an application, the county shall report the disposition of the application. This form shall be used to initiate assistance if the application is approved.

 

History Note:        Authority G.S. 143B‑153;

Eff. January 1, 1983;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0608        NOTICE TO APPLICANT

The director of the County Department or his or her designee shall notify the applicant or his or her Authorized Representative or any designated person, in writing of the disposition of the application.  The notification for approval must include the effective date of eligibility for the State/County Special Assistance Program.

 

History Note:        Authority G.S. 108A-40; 108A-79; 143B-153;

Eff. June 1, 2016.

 

SECTION .0700 - REDETERMINATION OF ELIGIBILITY

 

10A NCAC 71P .0701        TIME AND CONTENT

All eligibility factors as set forth in Rules .0804 and .0805 of this Subchapter that are subject to change shall be reviewed at least once every 12 months, before the recipient receives the 13th State/County Special Assistance Program payment. The eligibility factors subject to change include:

(1)           place of residence;

(2)           level of care;

(3)           income;

(4)           resources; and

(5)           change in household composition.

The Caseworker shall also evaluate the effect on eligibility of any Change in Situation reported by the recipient, his or her Authorized Representative, or made known to the Caseworker by another method.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0702        VERIFICATION OF FACILITY RESIDENCE

The Caseworker shall verify the Adult Care Facility residence for each recipient in all cases due for a review each month. This Rule shall not apply to recipients eligible for the State/County Special Assistance for the Certain Disabled Program and State/County Special Assistance In-Home Program.

 

History Note:        Authority G.S. 108A-40; 108A-41; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0703        INTERVIEW AND RECOMMENDATION

(a)  The recipient's rights and responsibilities shall be explained as specified in 10A NCAC 71P .0602.

(b)  Following the interview the eligibility worker shall recommend action.

 

History Note:        Authority G.S. 143B‑153;

Eff. January 1, 1983;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0704        RE-EVALUATION

 

History Note:        Authority G.S. 143B-153; S.L. 1999-237;

Temporary Adoption Eff. January 1, 2000;

Eff. July 17, 2000;

Repealed Eff. June 1, 2016.

 

10A NCAC 71P .0705        NOTICE TO RECIPIENT OF INTENDED ACTION

The director of the County Department or his or her designee shall notify the recipient and his or her Authorized Representative or any designated person, in writing of any intended action to terminate or modify the recipient's State/County Special Assistance Program payment, as follows:

(1)           Notice shall be sent no later than 10 business days before the proposed action becomes effective, as authorized by 108A-79(b). 

(2)           Notwithstanding the requirements of Item (1) of this Rule, an action to modify or terminate the payment shall be effective immediately, as authorized by G.S. 108A-79(b), 10A NCAC 67A .0202, and 42 CFR 431.213(a) through 42 CFR 431.213(f), in the following circumstances:

(a)           the County Department terminates the State/County Special Assistance Program payment based on verification of the death of the recipient;

(b)           the recipient is admitted to a public institution and no longer qualifies for assistance;

(c)           the recipient signs and dates a written request to have the State/County Special Assistance Program terminated or reduced;

(d)           the recipient is placed in skilled nursing care, intermediate care, or long-term hospitalization;

(e)           the recipient's whereabouts are unknown and agency mail has been returned by the post office indicating no known forwarding address; or

(f)            the modification is beneficial to the recipient.  

(3)           All notices of action shall contain information set forth in G.S. 108A-79(c). 

 

History Note:        Authority G.S. 108A-40; 108A-79; 143B-153;

Eff. June 1, 2016.

 

SECTION .0800 - COVERAGE

 

10A NCAC 71P .0801        AA-SA: GROUP I

10A NCAC 71P .0802        AD-SA: GROUP I

10A NCAC 71P .0803        SAA

 

History Note:        Authority G.S. 108A-41(b);143B-153;

Eff. January 1, 1983;

Temporary Amendment Eff. October 28, 1997;

Amended Eff. April 1, 1999;

Repealed Eff. June 1, 2016.

 

10A NCAC 71P .0804        PERSONS WHO ARE ELIGIBLE FOR THE STATE/COUNTY ASSISTANCE PROGRAM

The State/County Special Assistance Program shall be provided only for persons who:

(1)           meet one of the following age or disability requirements:

(a)           are aged 65 or older;

(b)           are aged less than 65 and are disabled or legally blind, pursuant to G.S. 108A-42(a) and the Social Security Act 42 U.S.C. 1382c.; or

(c)           are aged less than 18 and legally blind.

(2)           reside in duly licensed Adult Care Facilities or reside in an in-home living arrangement if eligible for the State/County Special Assistance In-Home Program;

(3)           receive SSI or are financially ineligible for SSI solely due to excess income;

(4)           are in need of the level of care provided in licensed Adult Care Facilities;

(5)           are not inmates of public institutions;

(6)           reside in North Carolina voluntarily with the intent to remain and meet the North Carolina residency requirement for the State/County Special Assistance Program pursuant to Rule .0903 of the Subchapter;

(7)           are U.S. citizens or qualified aliens as set forth is Rule .0902(a)(2) in this Subchapter;

(8)           meet income requirements as set forth in Rule .0905 of this Subchapter; and

(9)           meet resource requirements as set forth in Rule .0904 of this Subchapter.

 

History Note:        Authority G.S. 108A-40; 108A-41(b); 108A-42; 143B‑153;

Eff. January 1, 1983;

Temporary Amendment Eff. October 28, 1997;

Amended Eff. June 1, 2016; April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0805        STATE/COUNTY SPECIAL ASSISTANCE FOR THE CERTAIN DISABLED PROGRAM

The State/County Special Assistance for the Certain Disabled Program shall be provided only for persons who are:

(1)           ineligible for SSI and are not receiving SSI;

(2)           aged 18 or older and less than 65;

(3)           in need of the level of care provided in licensed Adult Care Facilities;

(4)           not inmates of public institutions;

(5)           residing in North Carolina voluntarily with the intent to remain and meet the North Carolina residency requirement for the State/County Special Assistance Program;

(6)           U.S. citizens or qualified aliens as set forth is Rule .0902(a)(2) in this Subchapter; and

(7)           not receiving Medicaid for the same month as they would receive State/County Special Assistance for the Certain Disabled Program.

 

History Note:        Authority G.S. 108A-25; 108A-40; 108A-41(b); 108A-41(d); 143B-153;

Eff. January 1, 1983;

Amended Eff. November 2, 1992; February 1, 1986;

Temporary Amendment Eff. October 28, 1997;

Amended Eff. June 1, 2016; April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

SECTION .0900 ‑ ELIGIBILITY FACTORS

 

10A NCAC 71P .0901        AGE

Verification of age is required for all applicants, or recipients by documentary evidence. If age cannot be verified in the time limit for processing the application, the worker shall use a temporary determination of age.

 

History Note:        Authority G.S. 108A-41; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 1990; February 1, 1986;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0902        UNITED STATES CITIZENSHIP

(a)  Eligibility Requirement. A recipient shall be:

(1)           A citizen of the United States; or

(2)           An alien lawfully admitted for permanent residence or an alien residing in the United States under color of law;

as set forth in 20 C.F.R .416.1600 through .1618.

(b)  Verification. The Caseworker shall require documentary evidence from the applicant or recipient to verify citizenship or alien status.

 

History Note:        Authority G.S. 108A-40; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; June 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0903        RESIDENCE

(a)  State Residence Eligibility Requirement. An individual shall meet the requirements in G.S. 108A-41(b)(3) to be eligible for the State/County Special Assistance Program.

An individual who moves to another state and intends to remain there shall not be eligible for the State/County Special Assistance Program.

(b)  County Residence Eligibility Requirement:

(1)           An individual shall be a resident of the county in which he or she lived in an in-home living arrangement prior to entering an Adult Care Facility.

(2)           If a disabled adult child as defined in 20 C.F.R. 404.350 has remained in a facility such as an Adult Care Facility, he or she remains a resident of the county and state in which his or her parent(s) resided immediately prior to him or her reaching age 18. If he or she is an adult and is entering an Adult Care Facility and it is not possible to trace his or her county of residence as a minor, he or she may establish residence based on his or her intent to remain regardless of his or her parent's current legal residence.

(c)  Temporary Absence.

(1)           An applicant or recipient shall not receive the State/County Special Assistance Program payments for those days he or she is not living in the Adult Care Facility unless his or her absence is not expected to exceed 30 calendar days. This Subparagraph (c)(1) shall not apply to recipients of the State/County Special Assistance In-Home Program or State/County Special Assistance for the Certain Disabled Program.

(2)           Temporary absence from the State or county of residence with subsequent return or intent to return does not make a recipient of the State/County Special Assistance for Certain Disabled Program in an in-home living arrangement ineligible for such assistance.

(d)  Verification. The Caseworker shall accept the applicant's or recipient's statement regarding residence unless the Caseworker has information that conflicts with the applicant's or recipient's statement. If there is conflicting information, documentary evidence from the applicant or recipient shall be required.

(e)  If a recipient of the State/County Special Assistance for Certain Disabled Program visits another county within the State or another state for a period exceeding three months, the Caseworker in the responsible county shall verify the following:

(1)           the recipient's intent to return;

(2)           the reason for the continuing absence; and

(3)           the continuing maintenance of a home in the responsible county.

 

History Note:        Authority G.S. 108A-40; 108A‑41; 108A-41(b); 143B‑153; 42 U.S.C. 1382e(c)(1);

Eff. January 1, 1983;

Amended Eff. June 1, 1990;

Temporary Amendment Eff. October 28, 1997;

Amended Eff. June 1, 2016; April 1, 1999;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0904        RESources

(a)  Eligibility shall be determined using the resource rules governing the SSI Program found in Title XVI of the Social Security Act as codified in 42 U.S.C. 1382b, which is hereby incorporated by reference including all subsequent amendments and editions. This law can be accessed free of charge through the federal Social Security website at www.ssa.gov.

(b)  Mental Competence: When an applicant's or recipient's competence is in question and there is no Authorized Representative, resources shall be counted according to 10A NCAC 23E .0202(b) through .0202(i).

 

History Note:        Authority G.S. 108A-40; 108A-41; 108A-46; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; February 1, 1996; July 1, 1994; March 1, 1991; June 1, 1990.

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0905        INCOME

Eligibility Requirement. Eligibility shall be determined using the income rules governing the SSI Program found in Title XVI of the Social Security Act as codified in 42 U.S.C. 1382a, which is hereby incorporated by reference including all subsequent amendments and editions. This law can be accessed free of charge through the federal Social Security website at www.ssa.gov.

 

History Note:        Authority G.S. 108A-26; 108A-40; 108A-41; 143B-153;

Eff. January 1, 1983;

Amended Eff. June 1, 2016; February 1, 1996; July 1, 1994; March 1, 1991; June 1, 1990;

Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. May 20, 2017.

 

10A NCAC 71P .0906        EVALUATION

 

History Note:        Authority G.S. 143B-153; S.L. 1999-237;

Temporary Adoption Eff. January 1, 2000;

Eff. July 17, 2000;

Repealed Eff. June 1, 2016.