DHB ADMINISTRATIVE LETTER NO: 05-21 AMENDED 2

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DHB ADMINISTRATIVE LETTER NO: 05-21

AMENDED 2, MEDICAID/NCHC

PROCEDURES FOR COVID-19 –

ALLOWABLE PROGRAM CHANGES AND

TERMINATIONS

DATE: February 14, 2023

SUBJECT: Medicaid/NCHC Procedures Due to COVID-19

Public Health Emergency – Allowable Program

Changes and Terminations – Amended 2

DISTRIBUTION: County Departments of Social Services

Medicaid Supervisors

Medicaid Eligibility Staff

BACKGROUND

On March 13, 2020, the President issued a proclamation declaring a national emergency

concerning the Coronavirus Disease outbreak (COVID-19).

The purpose of this letter is to provide instructions and clarification for circumstances

where certain program changes and/or case terminations are allowed during the COVID-

19 Public Health Emergency (PHE).

As a reminder, counties should continue to follow recertification/change in circumstance

procedures found in DHB Administrative Letter 09-20, Amended, Recertification

Procedures for COVID-19.

DHB Administrative Letter 02-21, NC Health Choice (NCHC) Beneficiary at the Age of

19 Procedures and Reports, is now obsolete. Information from DHB

Administrative Letter 02-21 that continues to be relevant has been included in this letter,

see section IV, below. In addition, guidance is provided for all NCHC beneficiaries who

are determined ineligible during the PHE.

This Administrative Letter is being amended for a second time due to new guidance from

the Centers for Medicare and Medicaid Services (CMS). Previous instructions in section

III.D. have been removed as they are now obsolete.

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II.

RECERTIFICATION/CHANGE IN CIRCUMSTANCE POLICY REGARDING

ALLOWABLE TERMINATIONS

Guidance provided in section III, below, is in addition to guidance found in DHB

Administrative Letter 07-21, Recertification Procedures for COVID-19.

During the COVID-19 Public Health Emergency (PHE), caseworkers must not terminate

or reduce Medicaid eligibility. As a reminder, the following exceptions regarding

terminations are still applicable, as well as the other allowable reasons for changes and

terminations stated in this letter:

The beneficiary moves out of state

The beneficiary voluntarily requests termination of Medicaid/NC Health

Choice benefits

Death of the beneficiary

Beneficiary no longer meets the citizenship/immigration status requirements (see

DHB Administrative Letter 07-21, section III.D for more information)

III.

PROCEDURES

Centers for Medicare and Medicaid Services (CMS) has issued guidance regarding

programs which are considered to meet the criteria for Minimum Essential Coverage

(MEC).

Minimum Essential Coverage (MEC)

When a beneficiary who is eligible for a Medicaid program that meets the MEC

requirements has a change that results in eligibility for a different Medicaid program,

the change can be made if the new Medicaid program also meets the requirements for

MEC. In addition, a beneficiary is also considered to meet MEC when they are

receiving Medicare and a MQB product, see Section E., for additional guidance.

There are some exceptions which are outlined below. If the new program of eligibility

has less coverage, the change cannot be made.

1. MAF cannot be moved to MPW

2. Medicaid cannot be moved to NC Health Choice

Non-MEC Programs

There are currently only two Medicaid programs that do not meet MEC requirements:

1. Medicaid for Family Planning (MAF-D) and

2. Medicaid for COVID-19 testing (MCV).

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Changes allowed for these two programs are limited. The beneficiary can be moved

to a program with greater coverage but cannot be moved to one with a lesser coverage

benefit.

• MAF-D can move to a MEC program but cannot be moved to MCV.

• MCV can move to MAF-D or a program that meets MEC.

o An application for Medicaid is required when MCV beneficiaries

report a change that would potentially make them eligible for a

greater program, including MAF-D. Counties should make the

beneficiary aware of the application process when the change is

reported.

Once the beneficiary is eligible for a program meeting MEC requirement, eligibility

must continue through the end of the month in which the PHE ends unless one of the

exceptions or allowable terminations included in this letter applies.

Allowable program changes

1. Certain changes are allowable if the new program allows the beneficiary to

continue eligibility with the same level of coverage. When the beneficiary is

currently eligible for a program that is considered MEC and reports a change

that results in eligibility in another program that meets MEC criteria, the

change can be made.

Example 1:

Mary and her 7-year-old son, Billy, are eligible for MAF-C. Mary reports at

recertification that she now has a part time job which increased her

household income above the MAF-C limit. Based on the new income, Billy is

now eligible for MIC-N. Because MIC-N meets the criteria for MEC, this is

an allowable change for Billy. Mary will move to Transitional Medicaid

(TMA).

This is an allowable change at recertification because MIC meets MEC

requirements for the child and the parent will continue to receive full

Medicaid through TMA, which is MEC.

During the PHE, if Mary has a change of circumstance or her recertification

must be completed that ends her TMA eligibility, the caseworker should

follow the procedures found in DHB Administrative Letter 09-20, Amended,

Recertification Procedures for COVID-19.

2. Changes cannot be made if the beneficiary will be moved to a lower level of

coverage or to a program within the same level but with less coverage.

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Example 2:

Johnny is receiving MAF-D only. At recertification, it is discovered that he is

no longer eligible for MAF-D or any other full Medicaid program but would

be eligible for MCV coverage only. Both MAF-D and MCV are considered to

be the same level of coverage, however, MAF-D provides a greater coverage

benefit for the beneficiary, therefore, Johnny must continue MAF-D during

the PHE. Follow procedures in DHB Administrative Letter 09-20, Amended,

Recertification Procedures for COVID-19.

3. As noted in example 2 above, MAF-D and MCV are in the same coverage

level. MCV eligible beneficiaries may be moved to MAF-D because it

provides greater coverage benefit. An application is required, see section

III.B. above.

Example 3:

Sally is eligible for and receiving MCV. She reports a change in circumstance

and is now potentially eligible for MAF-D. An application for Medicaid is

required. If Sally is determined eligible for MAF-D, authorize the MAF-D

case, and close the MCV case.

Allowable changes for dual eligible beneficiaries

Refer to DHB Administrative Letter 02-23, Medicaid Procedures Due to

COVID-19 Public Health Emergency – Change to Dually Eligible Procedures.

Evaluating and terminating cases authorized in error

Previous guidance advised counties that Medicaid could not be terminated, or benefits

decreased during the PHE, even if the case was authorized in error.

New guidance from CMS states that the requirement for continuous enrollment

applies only to those beneficiaries who are validly enrolled in Medicaid on or after

March 18, 2020. This applies to initial applications or recertifications that occurred

before March 18, 2020 as well as to applications or recertifications occurring during

the PHE.

When it is discovered at recertification or a reported change in circumstance that a

beneficiary has been authorized for Medicaid in error, the caseworker must evaluate

to determine if the beneficiary would be eligible based on the beneficiary’s current

circumstances.

A beneficiary is not considered validly enrolled when one of the following applies:

1. The determination of eligibility was incorrect at the time it was made due to

agency error.

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2. Eligibility was erroneously given due to beneficiary fraud or abuse. Fraud or

abuse is established when the beneficiary is convicted of fraud/abuse in a

court of law. Beneficiaries convicted of fraud/abuse by a court of law are

considered to be invalidly enrolled.

This does not apply when the applicant/beneficiary (a/b) makes a mistake or

inadvertent household error, or if fraud/abuse is suspected but not convicted.

If the a/b gave incorrect information by mistake and the information was

verified per applicable Medicaid or NC Health Choice policy, the a/b should

be considered to be validly enrolled.

a. Recertification:

(1)

Evaluate the beneficiary for all Medicaid/NC Health Choice

programs, including MCV.

(2)

If the beneficiary is now eligible under the same or greater

program, recertify the case. See MA-2320, Redetermination of

Eligibility, MA-3420, Re-Enrollment, and MA-3421 MAGI

Recertification.

(3)

If the beneficiary is now eligible for a lesser benefit, recertify after

timely notice requirements are met. See MA-2420/3430, Notice

and Hearings Process.

(4)

If the beneficiary is determined to be ineligible for all

Medicaid/NC Health Choice programs, terminate the case with

timely notice. See MA-2420/3430, Notice and Hearings Process.

b. Change of Circumstance:

(1)

Evaluate the beneficiary for all Medicaid/NC Health Choice

programs, including MCV.

(2)

If the beneficiary is now eligible under the same program, continue

eligibility for the remainder of the original certification period.

(3)

If the beneficiary is now eligible for a greater program, certify the

correct program for a new 6/12-month certification period.

(4)

If the beneficiary is now eligible for a lesser benefit, recertify after

timely notice requirements are met. See MA-2420/3430, Notice

and Hearings Process, then certify the correct program for the

remainder of the original certification period.

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(5)

If the beneficiary is determined to be ineligible for all

Medicaid/NC Health Choice programs, terminate the case with

timely notice. See MA-2420/3430, Notice and Hearings Process.

Excluding cases from automatic extension in NC FAST

In order to allow the termination of cases addressed in this letter, counties should

continue to notify their assigned OST representative of all cases that should not be

extended via the monthly batches for COVID Extensions, Hawkins Extensions, and

the End of the Month Data Fix. (See Amended DHB Administrative Letter 09-20 for

more information about these extensions.) Counties should send a list of all cases that

should be excluded from the extensions to their OST no later than the third to the

last workday of each month. Failure to provide this information to your OST will

result in cases being extended in error.

IV.

NCHC BENEFICIARY OF ANY AGE WHO IS DETERMINED INELIGIBLE

CMS has provided guidance that any NCHC beneficiaries who are determined to be

ineligible for NCHC either at critical age review when the beneficiary turns age 19,

change of circumstance, or at recertification, are not protected in continuous coverage

during the PHE. These beneficiaries must be evaluated for all other Medicaid programs,

including MCV.

Counties should continue to work the Critical Age Report in NC FAST for beneficiaries

who turn age 19 and mark the report complete so the individual falls off the critical age

report.

June 2021 will be the last month that NCHC cases will be extended via the COVID

extension and monthly data-fix. When the county discovers that a NCHC beneficiary no

longer meets the eligibility requirements for NCHC, either at critical age review, change

of circumstance, or at recertification, the caseworker should follow applicable policy

found in MA-3255, NC Health Choice, and MA-3430, Notice and Hearings Process.

Counties should work the pending recertification report and prioritize NCHC cases

previously extended in NC FAST due to COVID-19.

Caseworkers should complete an ex-parte review following policy in MA-3421, MAGI

Recertification.

As a reminder:

Requesting Information

1. Recertification – eligibility determination completed at the end of certification

period requires NCF-20020 if continuing eligibility cannot be established with

electronic matches or information in other cases.

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2. Redetermination – eligibility determination completed during the current

certification period when there is a change in circumstance, the DHB-5097 is

used to request any needed information. The NCF-20020 is not sent.

Outcomes

1. If the beneficiary is determined to be eligible for a greater benefit, authorize

the appropriate Medicaid program. Follow adequate notice policy found in

MA-3430, Notice and Hearings Process.

2. If the beneficiary is determined to be eligible for the lesser benefit of

Medicaid for Family Planning (MAF-D) or Medicaid for Coronavirus (MCV),

authorize the MAF-D or MCV case and follow timely notice policy found in

MA-3430, Notice and Hearings Process.

3. If the beneficiary is determined to be ineligible for all Medicaid programs,

terminate the NCHC case and follow timely notice policy found in MA-3430,

Notice and Hearings Process.

Example:

Jane, who is 10 years old, is receiving NCHC. At recertification, it is

determined that the household income is now above the allowable limits for

NCHC. The caseworker evaluates for all other Medicaid programs and Jane is

now only eligible for MAF-D. Timely notice is sent and Jane’s NCHC is

terminated, and she is placed in MAF-D.

Terminating NCHC in NC FAST

1. Caseworkers must ensure that a timely DSS-8110, Notice of Modification,

Termination, or Continuation of Public Assistance, is generated in NC FAST.

2. Select the correct reason, outcome, and change date. Follow NC FAST job

aid, MA/MAGI DSS-8110 Notice of Modification, Termination or

Continuation of Public Assistance.

3. Beginning in July 2021, NCHC Product Delivery Cases (PDC) will not be

extended via the monthly batches for COVID Extensions and the End of the

Month Data Fix.

4. NCHC PDC’s that the county is unable to complete the recertification or

change of circumstance timely will continue to be extended one month at a

time with the Hawkins extension batch.

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Hawkins v. Cohen procedures

Policy concerning Hawkins v. Cohen continues to apply. Before taking any action to

terminate or reduce benefits for these NCHC beneficiaries, the caseworker must

follow procedures found in DHB Administrative Letter 03-19, Hawkins v. Cohen

Procedures.

1. If it is determined that the beneficiary submitted or requested an application

for Medicaid for the Disabled (MAD) within the required timeframe found in

DHB Administrative Letter 03-19, the beneficiary’s NCHC benefits are

protected. The caseworker should follow guidance in Administrative Letter

03-19 to continue NCHC benefits until a disability decision is made.

2. Failure to complete the ex-parte review process in the required timeframe will

result in the NCHC eligibility being extended by NC FAST monthly via the

“Hawkins Extension” until the recertification is completed. These cases will

be listed on the Hawkins Extension Report

IMPLEMENTATION

These policies and procedures are effective immediately for applications and

recertifications. This also includes applications or recertifications currently in process.

Counties will be notified of any changes to the above guidance.

If you have any questions regarding this information, please contact your Medicaid Operational

Support Team representative.

Dave Richard

Deputy Secretary, NC Medicaid