North Carolina Administrative Code

subchapter 23c – application for medicaid benefits SECTION .0100 - APPLICATION PROCESS 10A NCAC 23c .0101 ACCEPTANCE OF APPLICATION (a) A client shall be allowed to apply without delay. Without delay is the same day the client appears at the county department of social services e…

10A NCAC 23c .0102 face-to-face INTERVIEW (a) The county department of social services shall conduct a face-to-face interview with the client or his representative who appears at the agency requesting financial or medical assistance. The client may have any person or persons of h…

10A NCAC 23C .0103 RECOMMENDATION FOR DISPOSITION (a) When all information necessary to determine eligibility has been obtained, the Income Maintenance Caseworker shall recommend whether to approve or to deny assistance. The recommendation shall be based on all reliable, relevant…

10A NCAC 23c .0104 DISPOSITION (a) Disposition of the application shall complete the application process and shall consist of one of the following actions: (1) Approval of assistance; (2) Denial of assistance; (3) Denial of assistance for ineligible month or months of the certifi…

10A NCAC 23C .0105 REFERRALS at a face-to-face interview For all Medicaid applicants who have a face-to-face interview at the county department of social services, the Income Maintenance Caseworker shall explain and make referrals for: (1) Health Check; (2) Family planning servic…

10A NCAC 23C .0106 MANDATORY USE OF OUTREACH LOCATIONS The county department of social services shall provide for the acceptance of applications and initial interviews for M-PW and M-IC coverage groups at certain outreach locations as follows: (1) disproportionate share acute car…

10A NCAC 23C .0107 hours for accepting financial and medical assistance applications The county department of social services must maintain the same number of operating hours as in February of 2002. Provisions must be made for acceptance of financial and medical assistance applic…

section .0200 – application processing, monitoring and corrective action 10A NCAC 23C .0201 APPLICATION PROCESSING STANDARDS (a) The county department of social services shall comply with the following standards in processing applications: (1) A decision shall be made within the …

10A NCAC 23C .0202 MONITORING THRESHOLDS AND CORRECTIVE ACTION (a) Division of Health Benefits employees, known as application monitors, shall review a random sample of applications in all county departments of social services and the Disability Determination Section (DDS) of the…

10A NCAC 23C .0203 TIMELINESS (a) Every month, each county department of social services and the Disability Determination Section (DDS) of the Division of Vocational Rehabilitation shall process applications as follows: (1) The average processing time (APT) for the county departm…

10A NCAC 23C .0204 LOCAL CORRECTIVE ACTION TEAM (a) The Assistant Director for Recipient and Provider Services (R&PS) in the Division of Health Benefits shall determine that a Local Corrective Action Team is needed when the county department of social services (DSS) is out of com…

10A NCAC 23C .0205 STATE CORRECTIVE ACTION TEAM (a) A State Corrective Action Team shall be convened by the Chairperson within 10 days when: (1) The county department of social services (DSS) has failed to meet the compliance thresholds by the date established by the local correc…

subchapter 23d - MEDICAID ELIGIBILITYGROUPS AND CLASSIFICATION SECTION .0100 – COVERAGE GROUPS 10A NCAC 23d .0101 MANDATORY GROUPS History Note: Authority G.S. 108A-54; 42 U.S.C. 1396a(a)(10); 42 U.S.C. 1396a(e)(4); 42 U.S.C. 1396a(f); 42 C.F.R. 435.110; 42 C.F.R. 435.112; 42 C.F…

10A ncac 23D .0102 OPTIONAL GROUPS History Note: Authority G.S. 108A-54; 42 C.F.R. 435.210; 42 C.F.R. 435.222; 42 C.F.R. 435.230; 42 C.F.R. 435.301; 42 C.F.R. 435.308; 42 C.F.R. 435.322; 42 C.F.R. 435.330; 42 U.S.C. 1396(a)(10)(A)(ii); 42 U.S.C. 1396a(a)(10)(C); S.L. 1983, c. 103…

section .0200 - classification 10A NCAC 23d .0201 CLASSIFICATION History Note: Filed as a Temporary Amendment Eff. October 1, 1994, for a period of 180 days or until the permanent rule becomes effective, whichever is sooner; Filed as a Temporary Amendment Eff. September 12, 1994,…

SUBCHAPTER 23E – MEDICAID ELIGIBILITY REQUIREMENTS SECTION .0100 – non-financial requirements 10A NCAC 23E .0101 AGE History Note: Authority G.S. 108A-54; 42 C.F.R. 435.520; Alexander v. Flaherty Consent Order filed February 14, 1992; Eff. September 1, 1984; Amended Eff. April 1,…

10A NCAC 23E .0102 UNITED STATES CITIZEN History Note: Authority G.S. 108A-54; 42 C.F.R. 435.402; 8 U.S.C. 1161; 8 U.S.C. 1255a; 42 U.S.C. 1396b(v); Eff. September 1, 1984; Amended Eff. August 1, 2000; December 1, 1991; August 1, 1990; Transferred from 10A NCAC 21B .0302 Eff. May…

10A NCAC 23E .0103 RESIDENCE (a) The requirements stated in 42 CFR 435.403 shall apply to determine residence in the State except for provisions in Paragraph (b) of this Rule. (b) Residents of the state of Georgia who enter a long term care facility in NC within 40 miles of the r…

10A NCAC 23E .0104 DEPRIVATION History Note: Authority G.S. 108A-28; 108A-54; 42 C.F.R. 435.510; 89 CVS 922; Eff. September 1, 1984; Amended Eff. October 1, 1991; August 1, 1990; Temporary Amendment Eff. August 5, 1999; Amended Eff. March 19, 2001; Transferred from 10A NCAC 21B .…

10A NCAC 23E .0105 DISABILITY (a) As set out in the Medicaid State Plan, individuals eligible for Medicaid in December 1973 as disabled individuals and who meet conditions required by 42 CFR 435.133 shall be permanently and totally disabled based on a physical or mental impairmen…

10A NCAC 23E .0106 BLINDNESS (a) To qualify for Medicaid under the category of Aid to the Blind, the client shall meet one of the following conditions: (1) receipt of Medicaid on the basis of blindness in December 1973, has continued to meet December 1973 eligibility criteria for…

10A NCAC 23E .0107 CARETAKER RELATIVE History Note: Authority G.S. 108A-54; 42 C.F.R. 435.310; Eff. September 1, 1984; Amended Eff. April 1, 1993; August 1, 1990; Transferred from 10A NCAC 21B .0307 Eff. May 1 2012; Repealed Eff. June 1, 2019.

10a NCAC 23E .0108 INMATE OF PUBLIC INSTITUTION OR PRIVATE PSYCHIATRIC HOSPITAL History Note: Authority G.S. 108A-54; 42 C.F.R. 435.1008; 42 C.F.R. 435.1009; S.L. 1987, c. 758, s. 69; Eff. September 1, 1984; Amended Eff. August 1, 1990; Transferred from 10A NCAC 21B .0308 Eff. Ma…

section .0200 – financial requirements 10A NCAC 23E .0201 APPLYING FOR ALL BENEFITS AND ANNUITIES (a) Clients shall follow all processes and procedures set forth by any financial institution or agency to obtain any annuities, pensions, retirement and disability benefits to which …

10A NCAC 23E .0202 WHAT RESOURCES ARE COUNTED (a) North Carolina has contracted with the Social Security Administration under Section 1634 of the Social Security Act to provide Medicaid to all SSI recipients. Except as specified in Paragraphs (j) and (k) of this Rule, the resourc…

10A NCAC 23E .0203 countable INCOME (a) For Family and Children's medically needy cases, income from the following sources shall be counted in the calculation of financial eligibility: (1) Unearned. (A) RSDI, as defined in 10A NCAC 23A .0102; (B) Veteran's Administration; (C) Rai…

10A NCAC 23E .0204 PERSONAL NEEDS ALLOWANCE History Note: Authority G.S. 108A-25(b); 42 C.F.R. 435.135; 42 C.F.R. 435.731; 42 C.F.R. 435.732; 42 C.F.R. 435.733; 42 C.F.R. 435.831; 42 U.S.C. 1383c(b); 42 U.S.C. 1383c(d); Eff. September 1, 1994; Transferred from 10A NCAC 21B .0313 …

10A NCAC 23E .0205 BUDGET UNIT MEMBERSHIP In aged, blind, and disabled cases and medically needy cases, the budget unit shall include individuals who are required by federal and State law to be financially responsible for the support of each other or other dependents. In all othe…

10A NCAC 23E .0206 FINANCIAL RESPONSIBILITY AND DEEMING History Note: Authority G.S. 108A-54; 143-127.1; S.L. 1983, c. 761, s. 60(6); S.L. 1983, c. 1034; S.L. 1983, c. 1116; 42 C.F.R. 435.602; 42 C.F.R. 435.712; 42 C.F.R. 435.734; 42 C.F.R. 435.821; 42 C.F.R. 435.823; Eff. Septem…

10A NCAC 23E .0207 WHOSE RESOURCES ARE COUNTED (a) The value of resources held by the client or by a financially responsible person shall be considered by the county department of social services to be available to the client in determining countable reserve for the budget unit. …

10A NCAC 23E .0208 calculating INCOME (a) Income that is actually available and the client or someone acting in his or her behalf has the legal authority to make available for support and maintenance shall be counted as income. (b) Only income actually available or predicted by t…

10A NCAC 23E .0209 DEDUCTIBLE (a) A deductible shall apply to a client in the following arrangements: (1) In private living quarters in the community; (2) In a residential group facility; or (3) In a long-term care living arrangement when the client: (A) Has enough income monthly…

10a NCAC 23E .0210 PATIENT LIABILITY (a) Patient liability shall apply to clients who live in facilities for skilled nursing, intermediate nursing, intermediate care facility for individuals with an intellectual disability, or other medical institutions. (b) The client's patient …

10A NCAC 23E .0211 ALIEN SPONSOR DEEMING (a) For purposes of this Rule, a "sponsored alien" means an alien who is lawfully admitted for permanent residence sponsored by an individual who has signed an Affidavit of Support required by U.S. Citizenship and Immigration Services. (b)…

SUBCHAPTER 23G – MEDICAID CERTIFICATION, CORRECTION OF ELIGIBILITY AND REDETERMINATION OF ELIGIBILITY section .0100 – medicaid certification 10A NCAC 23G .0101 CERTIFICATION AND AUTHORIZATION History Note: Authority G.S. 108A-54; 42 C.F.R. 435.112; 42 C.F.R. 435.914; Eff. Septemb…

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 the county department of social services discovers that prior actions we…

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, as described in 10A NCAC 23C .0101; (2) An appeal or court dec…

10A NCAC 23G .0203 TIME LIMITS FOR CORRECTIONS (a) The county department of social services and Division shall make corrections required by Rule .0202 of this Section within 30 days after discovery of the need for action unless good cause exists to extend the time limit. (b) For …

10A NCAC 23G .0204 RESPONSIBILITY FOR ERRORS (a) The Division shall be financially responsible for costs resulting from the erroneous issuance of benefits and Medicaid claims payments when: (1) Policy guidance given by the Division or its agents is erroneous and the Division dete…

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 E…

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 f…

10a NCAC 23G .0303 RECOMMENDATION 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; Repealed Eff. June 1, 2019.

10A NCAC 23G .0304 CHANGE IN SITUATION (a) For the purposes of this Rule, a "change in situation" includes: (1) Change of address; (2) Change in living arrangement; (3) Adding or deleting a budget unit member; (4) Increase or decrease in income; (5) Change in reserve; (6) Cessati…

subchapter 23H – Confidentiality and access to client records SECTION .0100 - General 10A NCAC 23H .0101 SCOPE The rules of this Subchapter protect the client's right to confidentiality. Non-identifying statistical information, general information about the scope of any programs …

10A NCAC 23H .0102 INFORMATION FROM OTHER AGENCIES If the agency receives information from another agency or individual, that information shall be treated as any other information generated by the Division of Health Benefits or the county department of social services, and disclo…

10A NCAC 23H .0103 CONFIDENTIALITY (a) Except as otherwise provided in these Rules it shall be unlawful for any person to obtain, disclose or use, or to authorize, permit or acquiesce to the use of any list of names or other information concerning any client applying for or recei…

10A NCAC 23H .0104 OWNERSHIP OF RECORDS (a) All client information contained in any records of the agency is the property of the agency, and employees of the agency shall protect and preserve such information from dissemination except as provided by the rules of this Subchapter. …

10A NCAC 23H .0105 SECURITY OF RECORDS (a) The agency shall provide a secure place or places with controlled access for the storage of records. Only individuals who must access client information in order to carry out duties assigned or approved by the agency shall be authorized …

10a NCAC 23H .0106 LIABILITY OF PERSONS WITH ACCESS (a) Failure to comply with the rules in this Subchapter is unlawful pursuant to G.S. 108A-80. (b) Individuals employed by the Division and county departments of social services and governed by the State Personnel Act are subject…

10A NCAC 23H .0107 RIGHT OF ACCESS (a) An individual has the right to obtain information about his or her own case. Upon written or verbal request, the client shall be able to review or obtain without charge a copy of the information in his or her records with the following excep…