Arkansas Administrative Code
Agency 016 - DEPARTMENT OF HUMAN SERVICES
Division 20 - Division of County Operations
Rule 016.20.13-004 - Arkansas Private Option (Health Care Independence Act of 2013) - Form DCO-151, Application for Health Coverage (Single Adults) Form DCO-152, Application for Health Coverage (Family), Medical Services Policy Manual Sections B100-270, E100-270, F 160-164 and F 180

1. The family must have become ineligible for TEA Medicaid due to increased wages or increased hours of employment (Re. MS Appendix M).

2. The family must have received TEA Medicaid in at least 3 of the 6 months immediate preceding the first month of TEA Medicaid ineligibility. Retroactive months count for this purpose (Re. MS Appendix M).

3. The family members must have been residents of Arkansas in the last month of TEA Medicaid eligibility, and must continue to reside in Arkansas.

4. There must be a dependent child under age 18 in the home (Re. MS Appendix M).

1. The family must have received TM in each month of the Initial 6 Months TM extension period.

2. There must continue to be a dependent child under age 18 in the home.

3. The parent (or non-parent specified relative) must have met the reporting requirements in the 1st and 4th months of the Additional TM Extension period (Re. MS 2061.7 and MS 2062.1).

4. The parent (or non-parent specified relative) must continue to be employed and receive earnings in each month preceding the 2nd and 3rd report periods of the additional TM extension period, unless good cause exists.

The average monthly gross earnings of the eligible members (less paid child care costs) cannot exceed 185% of the Federal Poverty Level (Re. FPL Chart at Appendix F).

Resources, deprivation, and unearned income are not eligibility factors for TM. A re-referral to OCSE is not required.

TEA Medicaid Case Closure - Due to Earnings

The Tea Medicaid case closure must be due solely to increased wages or increased hours of employment. If a TEA Medicaid family becomes ineligible due to earnings and for another reason in the same month, the family will be ineligible for Transitional Medicaid. For example, if the absent parent of all the TEA Medicaid children returns home and the caretaker parent becomes employed in the same month, the family will not be eligible for TM since earned income is not the sole reason for ineligibility. If, however, the TEA Medicaid family began receiving unearned income and earned income (of the caretaker parent) in the same month, a budget will be worked without the earned income. If the TEA Medicaid case remains eligible without the earned income and the inclusion of the earned income is the sole reason for TEA Medicaid closure, this requirement for TM has been met.

The increased earnings must be of the child's parent (or non-parent specified relative) who was included in the TEA Medicaid case as an eligible member in the last month of eligibility. The client's declaration of earnings will be accepted to determine continued Medicaid eligibility when the TEA cash assistance case closes due to employment. If at the first quarterly report the caseworker determines that the family should have remained in the TEA Medicaid, the case will be converted back to TEA Medicaid.

When it is determined that the family is ineligible for TEA Medicaid, and eligible for the Initial 6 Months Transitional Medicaid Extension, the caseworker will manually issue Form DCO-123 to notify the family of their TEA cash case closure; and to inform them of their eligibility for Transitional Medicaid and of the reporting requirement in the Initial 6 Months Transitional Medicaid Extension Period.

The TEA Medicaid case will be closed using "Convert to TM" and the appropriate reason will be entered in ANSWER. The earnings that resulted in TEA Medicaid ineligibility will be entered in ANSWER. The Transitional Medicaid case will be keyed to the WATM screen, using Form DCO-125, and the TEA Medicaid case number.

The Initial 6 Months TM Extension will begin with the first month following the last month of TEA Medicaid eligibility. The begin date will be entered in the Transitional Medicaid Begin Date on WATM. Individuals included in the budget group in the last month of TEA Medicaid eligibility will be entitled to the Initial 6 Months TM Medicaid Extension. Night Edit will convert the case to Category 25 for all open members if the income keyed, when calculated by the system, shows the case to be ineligible for TEA Medicaid.

Received TEA Medicaid in 3 of the last 6 Months

The family must have received TEA Medicaid in at least 3 of the 6 months immediately preceding the first month of TEA Medicaid ineligibility in order to qualify for TM. Eligibility for retroactive TEA Medicaid can count toward the 3 months. This requirement must always be met. For example, after receiving TM for 4 months or longer, if the parent (or non-parent specified relative) loses employment, receives TEA Medicaid for two months, than loses TEA Medicaid eligibility again due to employment, the family will not be eligible for TM, as they did not receive TEA Medicaid in 3 of the last 6 months immediately preceding the first month of TEA Medicaid ineligibility.

If a family received TEA in another state at any time during the 6 months immediately preceding the first month of TEA ineligibility, this period can be used to determine eligibility for TM.

The family will not be eligible for Transitional Medicaid if it is determined that the family was ineligible for TEA Medicaid at any time during the 6 months immediately preceding TEA Medicaid ineligibility due to fraud (under current policy, only a court can make a determination of fraud).

Residence

The family members must be residents of Arkansas at the time they became ineligible for TEA Medicaid, and must continue to reside in Arkansas throughout the Transitional Medicaid period. Residence is not affected by temporary absence from the state (e.g., on vacation). The TM case will be closed if the family moves out of Arkansas. Subsequently, if the family returns to Arkansas after the TM case has been closed, the TM case cannot be reopened. The family will have to make an application, and eligibility will be determined in another category.

Dependent Child

"Dependent Child" is defined, for TM purposes, as a child who is under age 18 who was living in the home in the last month of TEA Medicaid eligibility, and whose presence in the home helped establish TEA Medicaid eligibility. As a condition of TM eligibility, there must be a dependent child in the home in each month of TM. Eligibility for TM will terminate at the end of the first month in which the family ceases to include a dependent child. If the only dependent child leaves home and later returns after the TM case has been closed, the TM case may not be reopened, even if a portion of the 12 month TM period remains.

Reporting Requirements in the Initial 6 Months Transitional Medicaid Extension Period (First Six Months)

First Report

On the 6th workday from the end of the 3rd month of the Initial 6 Months Extension Period, the system will generate a notice and report form, DCO-124, to the family to be returned to the County Office by the 5th day of the 4th month. The parent (or non-parent specified relative) must report the household composition, the amount of gross earnings received, the amount of child care paid, and other circumstances which existed in the first 3 months of the Initial 6 Months TM Period. The DCO-124 will inform the family of its option for an additional 6 months period of TM which will be, in part, dependent upon the return of the DCO-124 report form in the 4th month of the Initial 6 Months TM Extension Period.

Upon receipt of a complete DCO-124, the County will key a "Y" in the "Report Received by County" field on WATM and will enter the date the report was received. This must be keyed to WATM no later than the 7th workday from the end of the 4th month. The earnings will be keyed into the income section in ANSWER, but continuing eligibility is not based on the amount of earnings received in the first 3 months of the Initial Extension Period. If there is any unearned income in the budget fields, it should be removed with zeros (00s). Zeros should also be entered in the deduction fields. The only entries needed in the budget fields are gross earned income and child care. The system will compute the net earned income.

1. Notice DCO-126 and Form DCO-124 will be manually issued to the parent (or non-parent specified relative) no later than the 1st workday following the 5th day of the report month. The DCO-126 will advise the parent (or non-parent specified relative) that the DCO-124 must be returned in 10 days, or eligibility will not be granted for the Additional 6 months TM Extension period.

2. If the client returns an incomplete DCO-124, the caseworker will mail the incomplete form back with the DCO-126 and advise the client in the space provided on the DCO-126 which questions must be completed or what verification is required. The client will also be advised that failure to return the completed DCO-124 in 10 days will result in ineligibility for the Additional 6 Months TM Period.

A "complete" DCO-124 is defined as one in which each "Yes or No" question is answered, the explanations related to a "Yes" response are completed, and required verification is attached. Part I, Household Information, will be considered complete if sufficient information is shown to determine household composition.

If the county has not keyed a "Y" to WATM by the 7th workday from the end of the month, the system will close the case with a Medicaid end date effective the last day of the 6th month and will send a closure notice to the family. If the client returns a complete report form after the 7th workday from the end of the 4th month and good cause for an untimely report is established, or the County failed to key a "Y" by the 7th workday from the end of the month, the County will reinstate the case in ANSWER and key "Y" in the Override Indicator" field on WATM and the date the report was received. The original Med Begin Date will be rekeyed and the Med End Date zeroed out. When the County reopens a case in this situation, it will not be necessary to register a new application.

T Note: Good Cause for untimely reports (DCO-124): An untimely DCO-124 is one which is received after the 10 day notice period specified on the DCO-126. The client must establish good cause for an untimely report in order for the report requirement to be met. The determination as to whether good cause exists for returning an "untimely" report will be left to the judgment of the caseworker, with approval by the Supervisor or his/her designated representative. Some examples of situations which might result in good cause are hospitalization, client is out of town, client's new address had not been keyed by County which resulted in the client not receiving the report form, etc.

Determining Initial Eligibility When There Was an Untimely Report of Earnings

In the event the County Office is not informed by a TEA Medicaid recipient of increased earnings in a "timely" manner, eligibility for Transitional Medicaid will be determined from the month the family actually became ineligible for TEA Medicaid.

If the County Office is informed of a TEA Medicaid family's increase in earnings as late as the 5th day of the 4th month of TEA Medicaid ineligibility, eligibility will be determined for TM in each of the months succeeding the last month of TEA Medicaid eligibility. If the eligibility requirements in the Initial 4 Months TM Extension period (MS Appendix M) are not met, no additional benefits will be authorized. If the eligibility requirements in the Initial 4 Months Extension period (MS Appendix M) are met, continuing TM benefits will be authorized. The County will manually issue Form DCO-124 to the family, if it is later than the 3rd month of TEA Medicaid ineligibility. This report must be returned to the County by the last day of the 4th month of the Initial TM Extension Period in order for the family to qualify for the Additional 6 Months TM Extension period.

If the earned income is reported or discovered after the 5th day of the 4th month of TEA Medicaid ineligibility, eligibility for the Initial TM period will be determined (for purposes of an overpayment only) but the family will not be entitled to receive any Additional TM benefits.

Determining Initial Eligibility When There Was an Untimely Report of Earnings

In the event the County Office is not informed by a TEA Medicaid recipient of increased earnings in a "timely" manner, eligibility for Transitional Medicaid will be determined from the month the family actually became ineligible for TEA Medicaid.

If the county Office is informed of a TEA Medicaid family's increase in earnings as late as the 5th day of the 4th month of TEA Medicaid ineligibility, eligibility will be determined for TM in each of the months succeeding the last month of TEA Medicaid eligibility. If the eligibility requirements in the Initial 4 Months TM Extension period (MS Appendix M) are not met, no additional benefits will be authorized. If the eligibility requirements in the Initial 4 Months Extension period (MS Appendix M) are met, continuing TM benefits will be authorized. The County will manually issue Form DCO-124 to the family, if it is later than the 3rd month of TEA Medicaid ineligibility. This report must be returned to the County by the last day of the 4th month of Initial TM Extension Period in order for the family to qualify for the Additional 6 Months TM Extension period.

If the earned income is report or discovered after the 5th day of the 4th month of TEA Medicaid ineligibility, eligibility for the Initial TM period will be determined (for purposes of an overpayment only) but the family will not be entitled to receive any Additional TM benefits.

Six Months TM Extension Period (Second Six Months)

In addition to continuing to meet each eligibility factor listed in MS Appendix M, the eligibility criteria specified in MS Appendix M must also be met for the Additional 6 Months of TM.

The family must have received TM in each of the 6 months of the Initial Transitional Medicaid Extension Period. If the TM case is closed at any point during the Initial 6 months Transitional Medicaid Extension period (e.g., no eligible child in the home or moved out of Arkansas

Reporting Requirements in the Additional 6 months Extension Period (Second Six Months)

Second Report

On the 6th workday from the end of the 6th month of the Initial 6 Months Extension Period, the system will generate a notice and report form, DCO-124; to those families who met the eligibility factors in the Initial 6 months Extension Period. This report should be returned to the County Office by the 5th day of the 1st month of the Additional 6 Months TM Extension Period (the 7th month). The parent (or non-parent specified relative) must again report the household composition, the amount of gross earnings received, the amount of child care paid, and other circumstances which existed in the last 3 months of the Initial TM Extension Period.

Upon receipt of a complete DCO-124, the caseworker will determine the client's continued eligibility for TM and, if eligible, the County will document the case.

1. Notice DCO-126 and Form DCO-124 will be manually issued to the parent (or non-parent specified relative) no later than the 1st working day following the 5th day of the month. The DCO-126 will advise the client that the DCO-124 must be returned in 10 days or the case will be closed.

2. If the client returned an incomplete DCO-124, the caseworker will mail the incomplete form back with the DCO-126 and advise the client, in the space provided on the DCO-126, which questions must be completed and what verification is required. The client will be advised that failure to return the DCO-124 in 10 days will result in case closure.

If a complete DCO-124 is not received by the 7th workday from the end of the 1st month of the Additional 6 Months Extension Period (the 7th month), the caseworker will close the case on WATM and in ANSWER with a Medicaid End Date effective the last day of that month. If the client returns the report form after the 7th workday from the end of the month, the case has been closed, and good cause is established, the caseworker will reopen in ANSWER, and WATM ("Convert to TM" and use the appropriate Action Reason, no new application necessary). The original Med. Begin Date will be entered, and the End Date will be zeroed out.

Third Report

On the 6th workday from the end of the 3rd month of the Additional 6 Months Extension Period (9th month), if the case remains open, the system will generate a notice and report form, DCO-124, to the family to be returned by the 5th day of the 4th month of the Additional Extension Period (10th month).

Upon receipt of a complete DCO-124, the caseworker will determine the client's continued eligibility for TM and, if eligible, the County will document the case.

1. Notice DCO-126 and Form DCO-124 will be manually issued to the parent (or non-parent specified relative) no later than the 1st working day following the 5th day of the month. The DCO-126 will advise the client that the DCO-124 must be returned in 10 days or the case will be closed.

2. If the client returns an incomplete DCO-124, the caseworker will mail the incomplete form back with the DCO-126 and advise the client, in the space provided on the DCO-126, which questions must be completed and what verification is required. The client will be advised that failure to return the DCO-124 in 10 days will result in the case closure.

If a complete DCO-124 is not received by the 7th workday from the end of the 4th month of the Additional 6 Months Extension Period (the 10th month), the County will close the case on WATM and in ANSWER, with a Medicaid End Date effective the last day of that month. If the client returns the report form after the 7th workday from the end of the month, the case has been closed, and good cause is established, the County will reinstate the case ("Convert to TM" and use the appropriate action reason, no new application necessary). The original Med. Begin Date will be reentered, and the Med. End Date will be zeroed out.

T Note: There are no automatic system closures in the Additional 6 Months Extension Period, except at the end of the 12th month.

Employment Requirement

In order for extended benefits to continue in the second 6-month period, the parent (or non-parent specified relative) must continue to be employed and receive earnings in each month preceding the 2nd and 3rd reports unless good cause exists.

Examples of good cause for loss of employment are illness, involuntary layoff, etc.

The 185% Earned Income Test and Computation of Average Monthly Gross Earnings

The family's average monthly gross earnings (less paid child care costs necessary for the parent, or non-parent specified relative, to maintain employment) cannot exceed 185% of the Federal Poverty Level (Re. FPL Chart at Appendix F).

1. Total for each month the earning received by all eligible family members in each of the 3 reporting months. Unearned income will be disregarded;

2. Subtract, from each month's total, the amount of child care paid in that month that was necessary for the parent ( or non-parent specified relative) to maintain employment (use the actual child care paid);

3. Add the net results from each of these months; and

4. Divide the result by 3.

This figure is the family's average monthly gross earnings.

EXAMPLE: A family of 4 has earnings and paid child care for the reporting period as follows:

$1,020.00 + $775.00 + $1,250.00 = $3,045.00 divided by 3 = $1,015 average gross monthly earnings. Compare the average gross monthly earnings to 185% of the Federal Poverty Level (Re. FPL Chart at Appendix F).

T Note: The FPL is adjusted annually due to changes in the Consumer Price Index. For continuing eligibility, the average monthly gross income, as computed above, will be compared to the FPL in effect during the report month, if different from the preceding months.

If the family's average gross monthly earnings (less paid child care) do not exceed 185% of Federal Poverty Level, the family will remain eligible. The case will be documented

If the family's average gross monthly earnings (less paid child care) exceed 185% of the FPL, the County will send a notice of closure to the family, and will key a closure to the Transitional Medicaid case in ANSWER with a Medicaid End Date effective the last day of the report month. Earnings that resulted in

Transitional Medicaid closure will be entered in the budget section. Night Edit will convert all open members in category 25 to closed status.

Changes in the Transitional Medicaid Period

Minor children entering the household, who were not in the budget group at the time the group became TEA Medicaid ineligible, will not be eligible for Transitional Medicaid and will not be added to the case. If an excluded child has earnings, they will not be considered in computing the family's average gross monthly earnings. The caseworker will determine eligibility for this child in another category, counting only the child and the child's parent(s) in the unit, and considering only their income.

Minor children, who were in the home and included in the TEA Medicaid case during the last month of TEA Medicaid eligibility, who later leave the home, will be dropped (a 10 day notice will be given). If he/she subsequently reenters the home while the family is receiving TM, he/she will be added to the Transitional Medicaid case. Any earnings that this child may have will be considered in computing the family's average gross monthly earnings.

The return of an absent parent to the home during Transitional Medicaid is not, in itself, a reason for closure (i.e., deprivation is not an eligibility factor for Transitional Medicaid). The absent parent, who returns, if he/she was not in the budget group at the time of the TEA Medicaid case closure, will not be eligible for Transitional Medicaid and will not be added to the case. Any earnings of the returning parent, however, will be used in computing the family's average gross monthly earnings.

If the only child in the home becomes eligible for SSI, the parent(s) (or non-parent specified relative) will remain eligible for Transitional Medicaid as long as the SSI child is under age 18. However, the County will receive a Systems Action Report notifying them that the case has been closed. The caseworker will reopen the Transitional Medicaid case for the adults(s) by using "Converting to TM" and the appropriate action reason. The Transitional Medicaid Status on WATM will be changed to open status. The adult(s) must continue to meet all other eligibility requirements in order to remain eligible for Transitional Medicaid.

System Closures, System Reports, and County Responsibilities

On the first workday of each month the system will search all Transitional Medicaid records for children who will reach the age of 18 that month. If the only child in the home is reaching age 18, the system will close the case and send a notice of case closure to the family. If there are other children under 18 in the home, the system will close only the 18-year-old and leave the remaining individuals open.

The Counties will receive a Systems Action Report that will inform them of Transitional Medicaid 18 year olds and cases closed by the system.

When the system has closed an 18 year old, or at any time a member or a case is found ineligible for Transitional Medicaid, the County Office will make a determination and document the case record as to whether or not the ineligible member(s) meets the eligibility criteria in any other Medicaid Category

(e.g., PW, MN-SD, etc.). If it appears that a member or the case would be eligible in another category, an application and notice of potential benefits will be sent to the individual(s).

During the Additional 6 Months TM Extension Period (Second Six Months), a monthly report titled "Transitional Medicaid Cases" will be generated to the Counties to assist them in tracking the Transitional Medicaid cases. This report will list the Case Number, Case head Name, Worker Number, Transitional Medicaid Begin Date, Current Month of Transitional Medicaid and the next month in which a Transitional Medicaid Report (DCO-124) is due.

At the end of the 12th month, the system will send a notice and close all Transitional Medicaid cases which remained open throughout both 6-month periods.

Summary of Sequence of Notices/Reports in Transitional Medicaid

Found TEA Medicaid ineligible prospectively. Determined Transitional Medicaid eligible:

* Form DCO-123 manually issued to family. Initial 6 months Extension Period

1st Month

* 1st month of TEA Medicaid ineligibility.

2nd Month 3rd Month

* Notice/Report Form DCO-124 system generated to case head on the 6th workday from the end of the month.

4th Month

* Case head must return DCO-124 with income and child care verification by the 5th day of the month. County completes DCO-125 and keys "Y" to WATM by the 7th workday from the end of the month. If the "Y" is not keyed, the system will generate a notice and close the case with a Medicaid End Date effective the last day of the 6th month.

5th Month 6th Month

* Notice/Report Form DCO-124 system generated to the case head on the 6th workday from the end of the month.

Additional 6 months Extension Period

7th Month

* Case head must return DCO-124 with income and child care verification by the 5th day of the month. If family eligible, County documents case. If family ineligible, County must key closure to ANSWER and WATM with a Medicaid End Date equal to the last day of the 7th month.

8th Month 9th Month

* Notice/Report Form DCO-124 system generated to the case head on the 6th workday from the end of the month.

10th Month

* Case head must return DCO-124 with income and child care verification by the 5th day of the month. If family eligible, County documents case. If family ineligible, County must key closure in ANSWER and WATM with a Medicaid End Date equal to the last day of the 10th month.

11th Month 12th Month

* System closes.

Extended Medicaid Eligibility When TEA Medicaid Case Closed Due to Child Support Income

Three months of extended Medicaid will be authorized when a TEA Medicaid case is closed due to child support income provided the case was open for at least three of the six months immediately preceding the first month of ineligibility. The three months will begin with the month following the first month in which the case became ineligible due to child support income. The TEA Medicaid ineligibility may have been caused in whole or in part by the child support income. Only those persons who were included in the budget in the last month of TEA Medicaid eligibility will be entitled to the three months of extended Medicaid.

Medical Services - Appendix N, Medically Needy Resource and income Levels 01/01/14

Medically Needy (MN) Resource Limitations for U-18 and Pregnant Woman (PW)

Resource eligibility for U-18 and PW is determined by computing countable resources as specified below in Part II and comparing them with the Medically Needy resource limitations. There is not applicable transfer of resource provision which applies to the U-18 and Pregnant Woman MN.

The following countable resource limitations are in effect for the Medically Needy Program U-18 and Pregnant Woman.

Resource Limits

1. Determination of Household Size for Medically Needy Resource Consideration

Household size for MN Resource determination is made according to categorical consideration.

2. Medically Needy Resource Determinations

Countable resources for Medically Needy are determined as follows according to categorical consideration.

1. Household size for MN income determination is made as follows according to categorical consideration.

1. Part A - Hospital Insurance - coverage is provided for inpatient hospital care, post hospital extended care and post hospital home health care and skilled nursing care. Part A pays Medicare per diem rate, less any unmet deductible(s) and/or coinsurance.

Under Part A - Medicare pays direct to the hospital/supplier. The hospital/supplier agrees to accept the Medicare per diem rate. The actual liability of the individual is limited to the following, where applicable:

o Inpatient Deductible, and/or o Blood Deductible, and/or o Coinsurance.

T Note: Medicare provides an unlimited number of hospital days after the annual Part A

deductible.

2. Part B, Medical Insurance - coverage is provided for physician services, supplies, home health care, outpatient hospital services, therapy and other services. Part B pays 80 per cent of the Medicare amount approved, less any unmet deductible.

Nonassignment - Under the nonassignment method, Medicare pays 80 per cent of their amount approved, less any unmet deductible, direct to the individual. The actual liability of the individual, (i.e., the difference between the amount billed by the physician/supplier and the amount paid by Medicare), is limited to the following, where applicable:

o Difference between amount billed and amount approved, plus o Deductible, and/or o 20 per cent coinsurance.

Assignment - Under the assignment method, Medicare pays 80 percent of their amount approved, less any unmet deductible, direct to the physician/supplier. The physician/supplier agrees to accept the amount approved by Medicare, (i.e., he discounts the difference between the amount billed and the amount approved by Medicare). The actual liability of the individual is limited to the following, where applicable:

o Deductible, and/or o 20 per cent coinsurance.

T Note: Some services are not covered under Part B. Where Medicare disallows a charge in its entirety (e.g. $10.00 billed, $0.00 allowed), the individual is liable for the full charge regardless of assignment.

Private Health Insurance

Private Health Insurance, like Medicare, consists of two types of coverage, Hospital and Medical.

For hospital care, private insurance makes reimbursement by means of per diem payments, percent of charge payments or a combination of the two.

Under the per diem method, the insurance will apply a fixed amount for each day of hospitalization, regardless of the total charges for the hospitalization.

Example: A child is hospitalized for 4 days; daily charges are $1200, $1100, $900 and $650 for days

1-4, respectively. The child's parents have insurance which pays a $600 per diem less any unmet deductible. The insurance payment and client's liability are determined, as follows:

Under the percent of charge method, the insurance will specify a fixed percent to be applied to the total charges for the hospitalization.

Example: Mr. Doe is hospitalized for 4 days, daily charges are $1200, $1100, $900 and $650 for days 1-4, respectively. Mr. Doe has insurance which pays 80 percent of total charges, less any unmet deductible. The insurance payment and Mr. Doe's liability are determined as follows:

The following is an example of a combination of the per diem and percent of charge methods:

Example: Mr. Doe is hospitalized for 4 days; daily charges, less room charge, are $1325, $1000,

$900 and $700 for days 1-4, respectively; the room charge is $250 a day. Mr. Doe has insurance which pays 80 per cent of total charge, less room charge, less any unmet deductible. The insurance also pays a $200 per diem on room charge. The insurance payment and Mr. Doe's liability are determined as follows:

Some private insurance (e.g., Medipak, which only covers the deductible and coinsurance charges that Medicare does not pay) provides limited coverage only.

Although private insurance offers an infinite variety of coverage plans, most companies make payment using one of the methods described or a similar method.

Nonmedical charges (e.g., charge for telephone, television, etc. while hospitalized) cannot be deducted from excess income even though the charges are a liability of the individual.

Nonspecific Assignable Payments

When a third party resource makes or indicates that it will make a nonspecific assignable payment (method of calculating payment is not known), the payment will be applied in the following manner.

Divide the nonspecific payment by total charges to determine the percent of payment. For cases in which the charges are not itemized (i.e. only a total summary of charges is available), it will be necessary to divide the charges by the dates of service to determine an average daily charge. Apply the percent of payment to each daily charge to determine the amount of charge covered by the payment. The balance of each daily charge (if any) is the liability of the individual.

Part II

Resources for U-18 and Pregnant Woman Medically Needy Spend Down Categories

The resource guidelines in this section provide general guidelines used in determining resource eligibility for U-18 and PW categories.

Definition of a Resource

A resource is any real or personal property available to an individual to meet his needs. Only those resources currently available, or for which the individual has the legal ability to make available, will be considered. Accumulations in trust funds, retirement and profit-sharing plans, or other arrangements which preclude the use of the property for meeting current needs will not be considered until such time as the property is actually available to the individual.

All or any portion of a payment which is considered as income in the month of receipt cannot be considered as a resource in the same month.

The equity value of all resources available to the assistance unit, except those specifically disregarded, must be determined. Equity value is the fair market value of the property less any liens or encumbrances.

The total equity value of all countable resources available to the assistance unit, except for that amount specifically disregarded from the equity of certain resources cannot exceed the resource limit for the category of Medicaid for which the client applied.

Resources to be Disregarded

1. The homestead (Refer to MS 11315);

2. Household furniture, appliances, and personal effects;

3. Farm or other equipment used to produce income;

4. The stock and inventory of a self-employment enterprise;

5. Livestock used for subsistence;

6. Loan obtained under Title III - EOA;

7. That portion of a grant, scholarship, payment under the Veterans' Educational Assistance Program (GI Bill), or unearned income paid to or for an individual conditioned upon school attendance which is used for items necessary for school attendance, such as tuition, books, fees, equipment, special clothing needs, transportation, and child care services.

8. Bona fide loans from any source (e.g., bank, any other establishment engaged in the business of making loans, or an individual). Refer to MS 11405. (Interest received on loans and retained in the months following the month the interest was received is considered a resource.)

9. Relocation allowances and adjustment payments made by Federal agencies under any federally financed relocation assistance program.

10. That portion of payments received as a settlement (insurance, law suit, etc.) which is intended and used for a specific purpose, such as medical bills, attorney's fees, etc. or as compensation for the loss of a resource (example - to repair or replace their vehicle).

11. Funds distributed to members of the Red Lake Bank of Chippewa Indian pursuant to Public Law 98-123, enacted October 13, 1983, and funds distributed to members of the Assiniboine Tribe of the Fort Belknap Indian Community and the Assiniboine Tribe of the Fort Belknap Indian Community and the Assiniboine Tribe of the Fort Peck Indian Reservation pursuant to Public Law 98-124, enacted October 13, 1983.

12. One burial plot per assistance unit member.

13. The total amount of federal tax refunds or advance payments for a period of 12 months after receipt. Earned Income Credit (EIC) payments are totally disregarded as income or resources.

14. Payments made from the Agent Orange Settlement Fund or any other fund established pursuant to the settlement in the In Re Agent Orange product liability litigation retroactive to January 1, 1989.

15. Payments made under the Radiation Exposure Act (Public Law 101-426) retroactive to October 15, 1990. These payments may be made to individuals in which injury or death resulted from the exposure to radiation from nuclear testing and uranium mining.

16. Payments made under the Civil Liberties Act of 1988 ( Title I of Public Law 100-383) and under the Aleution and Pribilof Islands Restitution Act ( Title II of Public Law 100-383) to Aleuts. These Acts provide for the federal government to make restitution payments to the individuals or if deceased, the individual's spouse, children or parents, who were interned during World War II.

17. Payments made under the Maine Indian Claims Settlement Act of 1980. These payments are made to members of the Passamaquoddy Indian Tribe, the Penobscot Nation and the Houlton Band of Maliseet Indians for the settlement of land claims.

18. Payments made under the Aroostook Bank of Micmacs Settlement Act. These payments are made to members of the Arrostook Bank of Micmacs for the settlement of land claims.

19. Major disaster and emergency payments made to individuals and families under the Disaster Relief Act of 1974 and comparable disaster assistance provided by States, local governments, and disaster assistance organizations.

20. Payments made from any fund established as a result of a class settlement in the case of Susan Walker vs. Bayer Corporation are in accordance with Section 4735 of the Balanced Budget Act of 1997 (Public Law 105-33) . This case involved hemophiliacs who contracted the HIV virus from contaminated blood products. Also excluded from countable resources are payments made pursuant to a release of all claims in a case that is entered into in lieu of the Walker vs. Bayer class settlement and that is signed by all affected parties on or before the later of December 31, 1997, or 270 days after the date on which the release is first sent to the persons to whom the payment is to be made.

NOTE: Interest earned by these lump sum funds and allowed to accrue is not excluded from countable resources.

The Homestead

The value of real property used by the assistance unit as a homestead is totally disregarded in determining Medicaid eligibility.

A homestead is a house and tract of land which a person considers his or her home. A mobile home or trailer used as a home will be considered as a homestead, regardless of whether the person also owns the property on which the mobile home is situated.

Only one such tract will be considered a homestead. However, there is no limit to the acreage or number of lots so long as the property is contiguous. Any other dwelling units or apartments on the property will be considered a part of the homestead.

The family must be presently residing on the property or intend to move on to it within a period of six months from the date of application or date of purchase, whichever is later.

If the family ceases to live on the property, it will continue to be regarded as a homestead for a period of six months from the date they left the home or the date of application, whichever was later, provided they intended to return to it. The recipient will be advised that the homestead becomes excess property after six months.

If the homestead is sold, the net proceeds received from the sale will be disregarded for a period of six months provided the casehead intends to apply such proceeds towards the purchase of another homestead. When the conditions of the sale of the homestead are such that the proceeds will be received through installment payments, then such proceeds will be disregarded as they are received provided they are applied to the payment of another homestead.

Only that portion of the proceeds, whether received in full or through installment payments, which are actually applied towards the purchase of the new homestead may be disregarded. Any remaining amount will be considered according to MS 11335, Items 2 or 3, as appropriate.

The casehead will be advised that if another homestead is not purchased within the six month period, then at the end of the six months the proceeds will be considered a resource if received in full, or as unearned income if received in installment payment. If a client who is receiving installment payments later purchases another homestead and applies the installment payment to the new home, then that portion applied may be disregarded.

Motor Vehicles

Each assistance unit will be allowed a disregard of $1500 of the equity in one motor vehicle. Equity is the vehicle's wholesale market value less any liens or encumbrances. The full equity value of any other vehicle owned by the persons whose resources must be considered plus any equity in the first vehicle in excess of the $1500 disregard is considered a resource.

Value determinations for vehicles will be made using one of the following web sites: CarPrices.com, Autopricing.com, Intellichoice.com, Edmunds.com, and Kelley Blue Book (kbb.com). No other web sites will be considered acceptable. A copy of the web page showing the vehicle value must be scanned into the electronic case record.

If more than one vehicle is owned, then the equity in each vehicle will be determined. Since the $1500 disregard can be applied to only one vehicle, it will be applied to the vehicle with the greatest equity value. No amount can be disregarded from the equity value of the remaining vehicles even if the value of the first vehicle was less than the $1500 disregard.

Value determination for other types of personal transportation such as boats, buses, motorcycles, etc., should be obtained by the caseworker through contact with a knowledgeable source such as a local dealer, automobile insurance company or the county personal property tax office. Complete information should be given to the contact regarding the particular make, model, and year of the motor vehicle. The case narrative should be documented as to the source of the valuation and the valuation given. If the casehead disagrees with the value determination, he or she may obtain at least two written appraisals of the value from knowledgeable sources. If the appraisals appear to be questionable, the caseworker should verify their accuracy with the knowledgeable sources. If the caseworker determines the appraisals are accurate, the equity in the vehicle(s) will be redetermined.

Jointly Owned Vehicles

When a vehicle is jointly owned by a Medicaid client and another person whose needs are not included in the same assistance unit, only the Medicaid client's prorata share of the vehicle's equity value will be considered. The $1500 disregard will be applied to the Medicaid client's share of the equity value (if not already applied to another vehicle).

This applies equally to situations in which the co-owner is, or is not, an SSI recipient. In either case, the Medicaid client's prorata share of the equity value will be considered in determining his/her Medicaid eligibility.

[] NOTE If a Medicaid client is the sole owner of a vehicle which was purchased with an SSI child's funds, then the full equity value is considered as belonging to the Medicaid client.

Determining Net Equity

1. Determine the amount of net equity in each vehicle owned by:

2. If the vehicle is jointly owned, determine the Medicaid client's prorata share of the net equity.

3. Subtract up to $1,500 from the client's net equity of the vehicle with the highest equity value. Any amount remaining of the $1500 disregard may not be applied to other vehicles.

4. Add the client's full net equity of any other vehicles to the amount remaining after the $1500 disregard. The total will be considered as a resource.

Funeral Arrangements

Each assistance unit member will be allowed a disregard of $1500 of the current equity value in funeral agreements. Any equity value in excess of $1500 is considered a resource.

The term "funeral agreements" includes burial insurance, pre-paid funeral arrangement contracts, and life insurance policies issued by funeral homes. The term "current equity value" is defined as the value of the agreement which can legally be converted to cash by the client.

If a funeral agreement has no current equity value, then it is not considered as an available resource. For example, a burial insurance policy with no cash surrender value or an irrevocable pre-paid funeral contract have no current equity value to the client.

Resources Considered in Full

Except for property specifically disregarded in MS 11310 or considered according to MS 11320 - 11322, the equity value of any other real or personal property available to the assistance unit will be considered in full.

When an applicant/recipient has joint ownership of a resource, their ownership interest and the availability of the resource to the assistance unit must be determined. If the resource is available to the unit, the net equity must then be determined.

Resources of an alien's sponsor and the sponsor's spouse must be considered as fully available to the alien and his or her family.

Requesting A Legal Opinion on Resource Ownership or Availability

1. The caseworker will scan the documents for the legal opinion request in the proper order into the eDoctus library, "County Request for Medicaid Decision." The proper order to scan documents into eDoctus can be found on the OPPD/OPLS legal document review check list.

2. This will trigger an email message to the Program Eligibility Analysts (PEA) for the area that the county office is located in.

3. The PEAs of the specified area will check the "County Request for Medicaid Decision" library on eDoctus to determine if the request originated in one of the counties he/she is responsible for.

4. The appropriate PEA will review the eDoctus documentation based on the guidelines provided by OPPD/OPLS legal document check list to ensure that the documentation is complete, in the proper order and ready for submission to OPPD.

5. Once the review is complete and any discrepancies have been corrected, the PEA will select the option of submitting the request to OPPD.

6. OPPD will review and submit the request to OPLS if needed. OPPD will provide an opinion on the requests that do not require an opinion from OPLS.

7. All opinions will be forwarded in an email message to the PEA and the county worker who requested the opinion.

8. The county worker will index the document in the client's electronic record. The Medicaid Eligibility Unit will scan the opinion into the client's electronic record on eDoctus.

Sale of a Resource

The sale of a resource, including disregarded resources, is considered a conversion of one type of resource (property) to another type (cash) except when the terms and conditions of the sale preclude the seller's ability to obtain full payment on demand. When an individual sells either real or personal property, the caseworker will determine the amount the individual received for the property and any terms or conditions of the sale.

1. If the homestead was sold, refer to The Homestead section above.

2. If the individual received full payment for the property, apply the amount received to the resource limit.

3. If the individual entered into a legal agreement or contract with the buyer by which payment is made through installment payments, then the caseworker will determine whether the individual can require full payment on demand.

If the entire balance is payable on demand, then the individual's equity in such balance will be applied to the resource limit. If such amount, combined with other countable resources, does not exceed the resource limit and the case remains eligible, then only the interest portion of the installment payment will be considered as unearned income. The individual's equity in the balance will continue to be applied to the resource limit.

If the entire balance is not payable on demand, then the entire installment payment, less any amount for which the seller is obligated to pay on the sold property, will be considered as unearned income.

Excess Real Property

The equity value of any real property not used as a homestead (excess property) will be considered a resource in determining Medicaid eligibility.

Determining Ownership

Ownership will be verified by deeds, wills, contract of purchase or other documentary evidence. When two or more persons own an interest in the property, the client's ownership interest and the availability of the property as a resource to the assistance unit must be determined (Refer to MS 3331.2 - 3331.3).

Questions of title, ownership, and property interest which cannot be resolved by the County Office will be submitted by e-mail or memorandum to the Office of Program Planning and Development, Slot S333 following procedures at (MS 11330).

Determining Market Value and Net Equity

1. Real estate brokers.

2. Local office of the USDA, Rural Development (for rural land).

3. Local office of the USDA, Farm Services Agency (for rural land).

4. Banks, savings and loan associations, mortgage companies, and similar lending institutions.

5. County Cooperative Extension Service (for rural land).

The estimate must be written, signed and dated, and have enough information so the source can be identified.

The client will be primarily responsible for obtaining the estimate. However, if requested, the caseworker will assist the client or attempt to obtain a free estimate. If an estimate cannot be obtained from any other knowledgeable source, then the assessed value from the tax assessor of the county in which the property is located, multiplied by the county multiplier, 5, will be used. If this method is used, the narrative will be updated in the electronic record to document that no other knowledgeable source estimate could be obtained.

Only the net equity in the property will be considered. Net equity is determined by subtracting the value of any liens, mortgages, or other encumbrances from the market value. If the market value of the property exceeds the maximum limitation, the amount of any encumbrances will be verified.

Personal Property

Personal property is property other than real property and consists primarily of liquid assets. Ownership of personal property can be in the same form as real property. Refer to MS E-512 concerning forms of ownership. The following sections describe more commonly held types of personal property.

Cash and Money on Deposit

Cash on hand includes amounts that the individual has on his person and amounts that he has at home. This amount, less any received during the month and counted as income, is a countable resource.

Money on deposit in a bank, savings and loan, credit union, or other financial institution must be considered a countable resource. Money on deposit includes checking accounts, savings accounts, certificates of deposit, retirement accounts, etc.

Jointly Held Bank Accounts With Non-SSI Recipients

When a Medicaid client has a bank account with a non-SSI person, ownership of the jointly held bank account must be determined prior to determining whether it is a resource to the client. This applies to all situations in which at least one of the persons named on the account, including the client's spouse, is a non-Medicaid person whose resources would not be considered in determining eligibility. (If one of the persons named on the account is an SSI recipient, see the Section below.) A person is considered as the owner of funds in a bank account if that person earned, received, or was given the funds in the account.

As this relates to married couples, for Medicaid purposes, it is normally presumed that both husband and wife are joint owners of funds in a jointly held bank account. However, when there is written documentation, clearly establishing that joint ownership is not intended, then ownership by just one will be determined to exist.

Ownership will be verified by written statements from the persons whose names are on the account, if at all possible, or if not, through collateral contacts. If it is determined that the Medicaid client does not actually own the funds in the account, then none will be considered a resource to the client. If joint ownership does actually exist, then the amount considered to be owned by each of the joint owners will be a prorata amount rather than the full amount.

Jointly Held Bank Accounts With SSI Recipients

Any funds in a jointly held bank account which are being considered in determining an SSI recipient's eligibility cannot be considered in determining eligibility for the Medically Needy categories. This applies to all situations in which a MN client's name is on a bank account with an SSI recipient, including situations in which the SSI recipient is the MN client's child or spouse.

SSI policy presumes that all funds in a bank account which is jointly owned by an SSI recipient and another person belong to the SSI recipient. The SSI recipient may rebut this presumption if some or all of the funds belong to the other person. However, unless the SSI recipient successfully rebuts the presumption, then SSI will consider all of the funds in the account for SSI purposes. In that case, none of the funds can be considered for MN purposes even if the MN client's name is on the bank account.

When a MN client's name is on any type of bank account with an SSI recipient, it will be presumed that all of the funds in the account are being considered for SSI purposes. It will not be necessary to verify with SSI whether the bank account funds are being considered for SSI purposes unless the MN client advises that SSI is not considering all of the funds, or the amount in the account would appear to cause SSI ineligibility if considered. In either of those situations, the Medicaid caseworker will verify with SSI

whether the funds are being considered in determining the SSI recipient's eligibility. Any funds not being considered for SSI purposes will be subject to MN consideration as described in the above section. That is, if the MN client is the only other owner, then the funds not considered for SSI will be considered for MN. If, though, there are other owners besides the MN client and SSI recipient, then ownership and prorata shares will be determined.

Except in the above two situations, it will not be necessary to verify with SSI whether the bank account funds are being considered for SSI purposes. It will be presumed that they are being considered for SSI and therefore, will not be considered for MN eligibility purposes.

Life Insurance Policies

The total cash surrender value (CSV) of all life insurance policies, except those issued by a funeral home and considered as a funeral agreement, will be considered when determining the resources available to the assistance unit. The cash surrender value of any life insurance policy which is accessible to any of the persons whose resources must be considered will be included regardless of whether the insured person is a member of the assistance unit.

Federal tax refunds or advance payments are excluded as income and disregarded as a resource for 12 months following the date of receipt. Earned Income Credit (EIC) payments are totally disregarded as income or resources.

Joint Refunds (Client and Spouse)

The client's portion of a joint tax return will be excluded as income and disregarded as a resource for 12 months following the date of receipt.

U.S. Savings Bonds

A U.S. Savings Bond is an obligation of the Federal government which is nontransferable. These bonds are normally owned by the owner(s) shown on the front of the bond. If bond ownership is shared, each person's share as a resource is equal, even though any of the owner's listed on the bond may dispose of it. Value determination should be secured by contact with a bank.

Stocks and Bonds

Shares of stock represent ownership in a corporation. Stock value is determined by the closing price at the time of application or redetermination. Verification of stock value may be made by consulting the financial section of a newspaper or on line listings. If these bids are not listed in the newspaper, contact will be made with a local securities firm for verification.

Other Types of Personal Property

Any other available property, including livestock not used for subsistence and farming or other self-employment tools and equipment which are no longer used to produce income, will be counted as a resource.

Medical Services - Appendix O, Renewal Forms Chart

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Appendix O - Renewal Forms Table

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APPENDIX P TEFRA

Premium Schedule How to determine TEFRA Premium Range

Stepl Look at the chart below. If the family has income after allowable deductions at or below the amount listed for the household size, a premium will not be assessed.

If the household has income that is greater than the amount listed below for the household size, continue to Step 2.

Step 2

Find the income here to determine the TEFRA Premium Range

Medical Services-Appendix Q, IRS Form Schedule C

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Medical Services - Appendix R, Transfer of Assets Divisor and Home Equity Limit

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Transfer of Asses Divisor

The divisor will be re-determined each year and any changes in the divisor will be effective on April 1st.

Home Equity Limit

The home equity limit is re-determined each year by CMS.

Medical Services - Appendix S, SSI and Quarters of Coverage Charts

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Effective 01/01/13

Amount Needed to Earn a Qualifying Quarter

Effective 01/01/12

Effective 01/01/11

Effective 01/01/10

Effective 01/01/09

Effective 07/25/08

Effective 01/01/08

Effective 01/01/07

Effective 01/01/06

Effective 01/01/05

Effective 01/01/04

Effective 01/01/03

Effective 01/01/02

Effective 01/01/01

Effective 01/01/00

Medical Services - Appendix T, Standard of Need

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Medical Services - Appendix U, Life Estate and Remainder Interest Tables

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Table - Unisex Life Estate or Remainder Table

Source: Section 20.2031-7 of Title 26 of the Code of Federal Regulations

Medical Services - Appendix V, Voter Registration

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Voter Registration

The National Voter Registration Act of 1993 (P. L. 103-31) requires each state's public assistance agency to provide the customer the opportunity to complete an Voter Registration Application at any time a request for assistance is made. This requirement became effective January 1, 1996.

Voter registration is not a part of program eligibility requirements. Therefore, an application for assistance will not be denied nor will a case be closed due to failure to complete any forms in relation to voter registration. No forms or other documents related to voter registration except for the DHS-131 and Voter Registration Change of Status will be filed in the customer's case record.

1. Seek to influence a customer's political preference or party registration;

2. Display any such political preference or party allegiance;

3. Make any statement to a customer or take any action, the purpose or effect of which is to discourage the customer from registering to vote; or

4. Make any statement to a customer or take any action, the purpose or effect of which is, to lead the customer to believe that a decision to register or not to register has any bearing on the availability of services or benefits.

Explanation & Offer

Each customer must be offered an opportunity to apply to register to vote when visiting the county office for purposes of applying for assistance, recertification/reevaluation, or for reporting changes of name or address. If a customer is applying for more than one service and is interviewed by two or more Program Eligibility Specialists on the same day, the offer has to be made at least once. The County Office will put into place a procedure that will ensure that the offer has been made.

Subsequent visits to the County Office for the purpose of completing the application/ recertification process (e.g., customer returns the next day to furnish check stubs) will be considered part of the same application. Therefore, it is not necessary to make another offer for voter registration.

Who Can Make the Offer

The offer can be made by any employee or volunteer. If the offer is made by someone other than the Program Eligibility Specialist, a procedure must be in place to notify the worker that the offer was made to avoid duplication of effort during the program eligibility interview.

A Voter Registration Application form must be provided to anyone who requests one. If someone is not applying for DHS services but requests a Voter Registration Application form, the worker will give him/her the form with instructions to mail it directly to the Secretary of State's office. A declaration form will not be given in this instance, nor will it count on the daily recap report.

Customer Acceptance

If a customer states she/he wishes to register to vote, she/he will be given a Voter Registration Application to complete. The voter registration application can be completed at the county office and given back to the receptionist or the customer can take it with him or her and mail directly to the designated address. Assistance in completing the form will be provided if requested. It is a local decision as to whether the Agency-Based Declaration Statement will be completed. If it is completed, a copy may be given to the customer if requested. It is a local decision as to whether the "yes" declarations will be kept in the county office. Do not mail the declaration forms to the Secretary of State's Office. The customer will be advised that a decision on his/her Voter Registration Application will be provided by the County Clerk's Office.

If there are other adult household members a Voter Registration Application may be given to the customer for the other adult(s) to complete. However, if the other adult(s) chooses not to register, a declination form is not needed.

The worker will put the agency code on the voter registration application that applies at the time it is being completed. For example, if the customer is applying for Supplemental Nutrition Assistance Program benefits at the time a voter registration application is being completed, the worker would use the SNAP code. If the customer is applying for several programs, just use one code (worker choice).

Telephone Interviews and Authorized Representatives

Applicants who are interviewed by phone and indicate a desire to register to vote should be mailed a Voter Registration Application no later than the date that a determination (approval or denial) is made on the case. This applies to both initial applications and reevaluation/recertifications.

The Voter Registration Application form will be mailed to the applicant/recipient any time an authorized representative is interviewed on the customer's behalf. If a customer makes a telephone request for a Voter registration Application form, one will be mailed to his/her mailing address.

Access Arkansas

Applicants who apply through Access Arkansas may apply directly online by following a link to the Secretary of State's website to register to vote.

SNAP/MSP Annual Review

Mail in applicants should be mailed an Arkansas Voter Registration Application no later than the date that a determination (approval or denial) is made on the case. This applies to both reevaluation/recertifications.

Customer Declination

If the customer declines to register to vote, then she/he will be asked to make the declination by checking "no" on the Agency-Based Declaration Statement. She/he should also sign and date the statement. If the customer refuses to complete the form, the DCO employee will print the customer's name on the statement, date, and make a note of "refused to sign" in the comment section. A copy of the Agency-Based Declaration Statement may be provided to the customer if requested. A daily count of the declinations must be provided to the Secretary of State's office when completing the Agency Daily Recap Reporting Form. The Agency Based Declaration Statement will be kept for 2 years in the County Office in a chronological file by month and year.

Change of Address or Name Change

If a customer reports a change of address or name change, a DCO-131, Voter Registration change of Status form and a Voter Registration Application will be sent to the customer advising that the change can be reported to the County Clerk's office for voter registration purposes or that she/he can register to vote. A declaration statement will not be completed in this instance.

Submitting Applications

Completed Voter Registration Applications must ensure that this timeframe is met. The customer may mail his/her application; the address is on the back of the application. An envelope is not needed. An Agency Daily Recap Reporting Form will be completed and sent with the voter registration application. This form advises the Secretary of State's Office of the number of declination and number of completed voter registration applications being submitted. A single report including all programs will be submitted. The County Office will retain a copy of the Daily Recap Reporting form for 24 months in a chronological file by month and year.

The County office must maintain a record of the number of Voter Registration applications mailed to the Secretary of State's Office each day. No later than the 10th calendar day of each month, the county will report to the DCO Field Operations, via the DHS-132, Voter Registration Application Monthly Report, the number of voter registration applications and declinations submitted to the Secretary of State's office in the prior month.

Medical Services - IRS Safeguards Appendix

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PURPOSE

Section 2651 of the Deficit Reduction Act of 1984 mandates that the Department of Human Services request and utilize IRS tax return information in determining eligibility for assistance. As a condition of receiving IRS tax return information, the Department of Human Services must establish and maintain safeguards designed to prevent unauthorized uses of the information and to protect the confidentiality of such information. This appendix specifically details the confidentiality and safeguard requirements that must be strictly followed.

Each DCO County Administrator has the responsibility of insuring that each employee is fully aware of the criminal and civil penalties for unauthorized disclosure of IRS tax return information. All information contained in this appendix must be reviewed by all staff semi-annually and each new employee must review this appendix prior to receiving and/or utilizing IRS tax return information.

Return information consists of more than an individual identity, amount and source of income, and other monetary values. Internal Revenue Code Section 6103 (b) (2), which defines return information, lists numerous items and continues with "...or any other data, received by, recorded by, furnished to, or collected by the Secretary with respect to a return or with respect to the determination of the existence, or possible existence, of liability...of any person..." "Even the existence or possible existence" of a tax liability has been interpreted (by IRS) to mean that the fact that IRS has information on an individual is considered return information. Any information showing that an IRS match occurred, reveals that IRS has information on that individual; therefore, such information is "return information".

Additionally, tax information never loses its character. That is, tax information remains tax information even after it has been verified. The major determining factor is the source of the information. If the initial source is IRS, the information is return information. If the initial source is the customer or a third party (from their records), the information is generally not return information. If a document contains return information and is verified by the customer or a third party, the information remains return information as the original source was IRS and it does not lose its character.

EMPLOYEE AWARENESS

Each agency employee entitled to access IRS tax return information must be thoroughly briefed on all security procedures and instructions. Periodic reorientation sessions should be conducted to insure that all appropriate employees remain alert to security requirements regarding IRS information.

In compliance with IRS Safeguard requirements, a poster has been developed advising employees of the penalties for unauthorized disclosure. Each DCO County Administrator has the responsibility of displaying the poster so that employees are reminded of the penalties. Penalties apply even if an unauthorized disclosure is made after employment with the agency is terminated. Unauthorized disclosure by current employees will result in termination.

Employees who are entitled to access IRS tax return information must not disclose this information to any party outside the agency other than the taxpayer to whom the information relates, the taxpayer's duly appointed representative who has the explicit written authority to obtain the information, or employees of the federal agency charged with oversight of the particular program the state agency is administering.

Employees who are entitled to access IRS tax return information must not disclose this information to any other officer or employee within the agency whose official duties do not require this information to determine eligibility for, or the correct amount of, benefits under these programs.

Due to stringent IRS safeguarding and disclosure guidelines it is necessary that employees exercise care in composing notices to customers and correspondence to payers with respect to IRS tax return information. It is recommended that notices to customers do not list the IRS as the source of the information but rather should state that the agency has learned about the information through computer matching.

If the customer questions the source of the information then the source of the information may be disclosed to the customer or his/her duly appointed representative. In the case of adults (including spouses) on whom an IRS report is generated, disclosure of the source of the information will be provided only to the adult for whom the information is reported. In the case of children on whom an IRS report is generated, disclosure of the source of the information will be provided only to the child's parent or guardian. Any correspondence written or verbal between the agency and the payer should not reference IRS as the data source.

OFFICE SECURITY AND RECORD RETENTION

All TEA, Food Stamp, and Medicaid case records will be kept in a locked storage area during non-working hours. Further, at no time will any IRS or BENDEX Wage report be left in open view so that unauthorized persons may gain access. IRS reports are generated under the title "State Resource" reports.

All IRS and BENDEX Wage summary reports will be maintained in the county office for one year from the report rundate and may be destroyed at that time following the procedures which follow.

DESTRUCTION OF IRS TAX RETURN INFORMATION

The Tax Reform Act of 1976 requires that certain actions be taken when destroying federal tax information in order to protect its confidentiality. IRS data will be destroyed by burning or shredding.

Burning: The material is to be either burned in an incinerator that produces enough heat to burn the entire bundle or the bundle should be separated to insure that all pages are consumed.

Shredding: To make reconstruction more difficult, the paper should be inserted so that the lines of print are perpendicular to the cutting line; small amounts of shredded paper should not be allowed to accumulate in the shredder bin.

IRS data in identifiable form must never be released to private contractors for unsupervised destruction. Destruction of the data must be witnessed by an agency employee in a manner sufficient to safeguard the data from unauthorized disclosure.

Each Economic Services Supervisor will have the responsibility of maintaining a Control Log of all IRS data that is destroyed. At a minimum, the log will contain the following:

* Date of destruction

* Method of destruction

* Printout number and rundate for summary reports

* Case name and number for cases containing IRS data

* Agency personnel responsible for overseeing destruction

Since IRS data must be logged when destroyed and since Individual Case Sheets will be filed in case records, it is necessary that case records be screened for IRS data prior to destruction. If tax return information is in the case record, then an entry to the IRS destruction log is required. To expedite the screening of cases for tax return data, enter "IRS" in the upper right corner of the face sheet of the case to alert staff that the case contains tax return information from the IRS. It is important that all offices use a consistent method to notate cases for IRS data since cases are often transferred between offices.

The Control logs will be forwarded to the Assistant Director of the Office of Program Planning and Development no later than August 15th of each year. A copy of the Control log will be retained in the county office for five complete years from the date of its submission to Central Office.

SAFEGUARD CONTROLS

A control list will be maintained in each DHS county office substantiating that each employee authorized to receive and use IRS tax return information has received a copy of the IRS Confidentiality and Safeguard Procedures and has been made fully aware of the penalties for unauthorized disclosure. Each new agency employee entitled to access IRS tax return information must also be added to the control list prior to accessing the data. This list will contain, at a minimum, the name and signature of the person responsible for IRS data, the date that safeguard procedures were reviewed and the supervisor's initials. The list is subject to review by the Management & Evaluation Unit, the Program Support Specialist, the Program Support Manager, and other Central Office staff as deemed necessary. In addition, the control list will be made available for on-site inspections made by the Internal Revenue Service.

ON-SITE INSPECTIONS

1. A review of the storage and handling of federal tax information;

2. A review of the dissemination of federal tax reports to appropriate agency staff;

3. An assessment of county office security features;

4. Verification that all IRS tax return is maintained in a locked storage area during non-working hours or that the county office is making a good faith effort to work toward such an arrangement;

5. A review of after-hours security to insure that unauthorized access cannot be obtained by unauthorized personnel (e.g., janitorial staff);

6. A review of all IRS Control Logs;

7. Interviews with appropriate agency staff to ensure that employees are aware of the confidentiality regarding IRS data and the penalties for unauthorized disclosure;

8. Verification that each county office has displayed the poster advising of the penalties for unauthorized disclosure of IRS information; and

9. A review of county office procedures for destruction of IRS information.

Arkansas Department of Human Services

Application for Health Coverage

Single Adults

Use this application to see what

coverage you qualify for through

DHS.

* Medicaid, ARKids First or the Health Care Independence Program

* If you are not eligible for any of the above coverage, your information will be transferred to the Federally Facilitated Health Insurance Marketplace to determine your eligibility for tax credits to help pay for a Qualified Health Plan.

Who can use this application?

Single adults who:

* Don't have any dependents and can't be claimed as a dependent on someone else's tax return.

NOTE: If any of the following apply you will need to fill out form DCO-152 to make sure you get the most benefits possible:

* You're married or have dependent children.

* You were in the Foster Care system and you're under 26.

* You have items that can be deducted from your income. If your only deduction is student loan interest, you can use this form.

* You're American Indian or Alaska Native.

Apply faster online. Apply faster online at Access.Arkansas.gov.

What you may need to apply.

* Your Social Security number (or document number if you're a legal immigrant).

* Employer and income information (for example, from paystubs, W-2 forms, or wage and tax statements.

Why do we ask for this information?

We ask about income and other information to let you know what coverage you qualify for and if you can get help paying for it. We'll keep all the information you provide private and secure as required by law. To view the Privacy Act Statement go to Access.Arkansas.gov.

What happens next?

Send your completed, signed application to the address on Page 4. If you don't have all the information we ask for, sign and submit your application anyway.

Get help with this application.

* Phone: Call our Help Center at 1-855-372 -1084.

* In person: Contact your local DHS county office for more information.

* En Español: Llame a nuestro centro de ayuda gratis al 1-855-372 -1084.

Step 1 - Tell Us About Yourself

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Step 2 - Current Job & I ncome Information

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Step 3 - Your Health Coverage

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Step 4 - Read & Sign This Application

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Step 5 - Submit Completed Application

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Arkansas Department of Human Services Application for Health Coverage

Use this application to see what coverage you qualify for through DHS.

* Medicaid, ARKids First or the Health Care Independence Program

* If you are not eligible for any of the above coverage, your information will be transferred to the Federally Facilitated Health Insurance Marketplace to determine your eligibility for tax credits to help pay for a Qualified Health Plan.

Who can use this application?

Use this application to apply for you or anyone in your family.

* Apply even if you or your child already has health coverage. You could be eligible for lower cost or free coverage.

* Families that include immigrants can apply. You can apply for your children even if you are not eligible for coverage. Applying won't affect your immigration status or chances of becoming a permanent resident or citizen.

* If someone is helping you fill out this application, you may need to complete a DCO-153, Consent for an Authorized Representative.

Apply faster online. Apply faster online at: Access.Arkansas.gov

What you may need to apply.

* Your Social Security number (or document number if you are a legal immigrant)

* Employer and income information (for example: from paystubs, W-2 forms, or wage and tax statements)

* Information about any job related health insurance available to your family

* Policy numbers for any current health insurance

Why do we ask for this information?

We ask about income and other information to let you know what coverage you qualify for and if you can get help paying for it. We will keep all the information you provide private and secure, as required by law. To view the Privacy Act Statement go to Access.Arkansas.gov.

What happens next?

Send your complete, signed application to the address on page 8. If you do not have all the information we ask for, sign and submit your application anyway.

Get help with this application.

* Phone: Call our Help Center at 1-855-372-1084.

* In person: Contact your local DHS county office for more information.

* En Español: Llame a nuestro centro de ayuda gratis al 1-855-372-1084.

Step 1 Tell Us About Yourself

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Step 2 Tell Us About Your Family

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Step 2: Person 1 (Start with yourself)

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Step 2: Person 2

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Step 3 American Indian or Alaskan Native (AI/AN) Family Members

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Step 4 Your Family's Health Coverage

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Step 5 Read & Sign This Application

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Step 6 Mail Completed Application

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