`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

(a)  A complete redetermination of the client's continuing

eligibility for Medicaid shall be completed by the following schedule:

(1)           At least once every 12 months for

categorically needy aged, blind, and disabled clients.

(2)           At least once every six months for

categorically needy clients under Family and Children-related categories.

(3)           At least once every six months for

medically needy clients.

(b)  Income shall be reverified at the end of six months for

categorically needy aged, blind, and disabled clients in long term care, or who

have a deductible, or who have sources of income not stable in amount or time

of receipt.

(c)  There shall be no redetermination of eligibility for M-PW

cases.

(d)  All eligibility conditions subject to change shall be

reviewed for each client at the redetermination and the results documented in

the case record.

 

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.

 

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.

 

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.