CHAPTER He-W 800  ELIGIBILITY FOR MEDICAL ASSISTANCE

 

PART He-W 801  RESERVED

 

PART He-W 802  PROGRAM COVERAGES AND LIMITATIONS

 

          He-W 802.03  Telephone Application.

 

          (a)  Applicants for any program of medical assistance except for medical assistance as described in He-W 858.05 and He-W 858.06, who request assistance via the telephone, shall be considered to have submitted an application as described in He-W 601.01(p).

 

          (b)  The telephone application process pursuant to (a) above shall only be available as funding and resources within the current state fiscal year are available.

 

          (c)  All the application requirements that apply when an individual submits a written application shall apply when an individual requests assistance via (a) above, including:

 

(1)  Verification requirements described in He-W 806;

 

(2)  Interview requirements described in He-W 636.01 and He-W 644.01; and

 

(3)  All program requirements as described in He-W 800.

 

Source.  #12552, eff 6-20-18

 

PART He-W 803  INDIVIDUAL RIGHTS AND RESPONSIBILITIES

 

He-W 803.01  Authorized Representative.

 

(a)  A individual who chooses an authorized representative (AR), as defined in He-W 601.01(w), to help with some or all the responsibilities of applying for or receiving medical assistance shall provide all of the following information in writing:

 

(1)  The name, address, and telephone number of the AR;

 

(2)  The duties that the AR will carry out, as specified in (c) below;

 

(3)  The individual's relationship to the AR;

 

(4)  A statement signed and dated by the individual acknowledging:

 

a.  His or her responsibility for any errors, omissions, failures to report information to DHHS, or inaccurate information reported to DHHS by the AR;

 

b.  That if the AR uses the individual’s benefits without permission, these benefits will not be replaced by DHHS;

 

c.  That the person the individual names as the AR will continue to act for the individual until the individual or the AR tells DHHS of a change; and

 

d.  Comprehension of the individual’s choice of AR and the duties assigned to that AR; and

 

(5)  A statement signed and dated by the AR:

 

a.  Agreeing to accept the responsibilities designated by the individual;

 

b.  Acknowledging that the AR understands that:

 

1.  Proof of the AR’s identity is required;

 

2.  If disqualified for a program violation, the person identified as the AR can no longer act as an AR unless there is no one else suitable to represent the individual; and

 

3.  The AR will continue to act as an AR for the individual until the AR or the individual tells DHHS of a change.

 

(b)  To qualify as an AR, an individual shall be an adult who has:

 

(1)  Expressed concern for the individual's wellbeing;

 

(2)  Sufficient knowledge about the individual's circumstances to assist the individual in applying for or receiving assistance; and

 

(3)  The capability to obtain information about the individual's circumstances.

 

(c)  The individual may authorize an AR to carry out one or more of the following responsibilities:

 

(1)  Obtaining DHHS applications and other forms or DHHS paperwork, and completing these for the individual;

 

(2)  Attending eligibility interviews for the individual;

 

(3)  Providing DHHS with verification of the individual's income, resources and other case circumstances;

 

(4)  Reporting and verifying changes in the individual's case circumstances to DHHS;

 

(5)  Receiving the individual's medical assistance identification card and other DHHS mail;

 

(6)  Asking for, attending, and representing the individual at administrative appeals for the individual;

 

(7)  Communicating with the individual’s managed care organization or qualified health plan; and

 

(8)  Any other duties regarding eligibility for medical assistance an individual chooses to designate to an AR.

 

(d)  If designated pursuant to (a)(2) above, ARs shall:

 

(1)  Sign DHHS forms completed on behalf of the individual; and

 

(2)  Co-sign DHHS forms they assist the individual in completing.

 

Source.  #11042, eff 2-24-16

 

He-W 803.02  Individual Responsibility to Supply Accurate Information.  Individuals shall supply complete and truthful answers to all written and verbal questions to establish eligibility or fulfill an eligibility requirement, pursuant to RSA 167:17-b.

 

Source.  #11042, eff 2-24-16

 

He-W 803.03  Individual Responsibility to Report Changes.  Failure to report changes no later than 10 calendar days after the change takes place, pursuant to RSA 167:17, shall result in the recoupment of any resultant overpayments or a corrective payment for any resultant underpayments.

 

Source.  #11042, eff 2-24-16

 

PART He-W 804  CASE DECISIONS

 

          He-W 804.04  Electronic Notification.

 

          (a)  Notices of decision (NOD), as defined in He-W 601.05(y), may be accessed electronically by the casehead, as defined in He-W 601.02(j), if the casehead:

 

(1)  Chooses to access NODs electronically;

 

(2)  Has an email account able to receive notifications from the department;

 

(3)  Provides the department with his or her email account address; and

 

(4)  Activates an account through the department’s eligibility web portal.

 

          (b)  If the casehead chooses to access NODs only electronically, no paper NODs shall be sent to the casehead via the mail.

 

          (c)  If the casehead chooses to access NODs only electronically, the casehead shall be responsible for the security and validity of the email account information provided to the department.

 

          (d)  All requirements that apply when the casehead receives a paper NOD shall apply when the casehead chooses to access NODs only electronically.

 

          (e)  If the casehead prefers to reestablish generation of paper NODs sent via the mail and chooses not to use the department’s eligibility web portal to make this change, he or she shall submit a request to the department in writing and include the following information:

 

(1)  The casehead’s printed name;

 

(2)  The request to reestablish generation of paper NODs;

 

(3)  The case number or recipient identification number (RID) assigned to the casehead’s case; and

 

(4)  The casehead’s signature.

 

          (f)  The date the department receives the completed request described in (e) above shall be the individual’s filing date for the request to reestablish paper NODs.

 

          (g)  Paper generation of NODs shall be generated to the casehead’s mailing address within 10 days of the individual’s filing date described in (f) above.

 

Source.  #10729, eff 11-25-14

 

          He-W 804.05  Electronic Account Access.

 

          (a)  Electronic accounts that contain the casehead’s electronic NODs and other confidential case information shall be activated through the department’s eligibility web portal by:

 

(1)  The casehead;

 

(2)  The casehead’s guardian, conservator, or protective payee;

 

(3)  An authorized representative or power of attorney chosen by the casehead; or

 

(4)  An organization acting as the casehead’s guardian, conservator, protective payee, authorized representative, or power of attorney.

 

          (b)  If an organization acting as the casehead’s guardian, conservator, protective payee, authorized representative, or power of attorney chooses to access a casehead’s electronic account, the organization shall:

 

(1)  Obtain the casehead’s permission to access the electronic account; and

 

(2)  Register with the department by providing the following information:

 

a.  The organization’s name, phone number, and street, mailing, and email address;

 

b. The name of a designated administrator for the organization who is responsible for maintaining confidentiality for the entire organization;

 

c.  A 4-digit pin, chosen by the administrator, for security purposes; and

 

d. The administrator’s dated signature signifying an agreement to abide by the confidentiality and safeguarding information policies, pursuant to RSA 167:31, RSA 167:32, and 42 CFR 431.300-42 CFR 431.307.

 

          (c)  A casehead shall not have access to an electronic account through the department’s eligibility web portal once the casehead has given permission to an organization to access the casehead’s electronic account.

 

          (d)  If the organization chooses to access NODs only electronically, with no paper NOD mailed, the organization shall be responsible for the security and validity of the email account information provided to the department.

 

          (e)  All requirements that apply when the casehead receives a paper NOD shall apply when the organization chooses to access NODs only electronically on behalf of the casehead.

 

          (f)  If the organization prefers to reestablish generation of paper NODs sent via the mail, the organization shall do so using the department’s eligibility web portal to make this change.

 

Source.  #10729, eff 11-25-14

 

PART He-W 805  RESERVED

 

PART He-W 806  VERIFICATIONS

 

Revision Note:

 

          Document #10743, effective 12-12-14, readopted with amendments He-W 606.89 titled “In and Out Medically Needy Medical Assistance” and renumbered the rule as He-W 806.89 titled “Verification Requirements for In and Out Medically Needy Medical Assistance”.  The source note information for He-W 806.89 prior to Document #10743 includes the documents filed under He-W 606.89.

 

          Although He-W 606.89 had last been filed under Document #8684, effective 7-21-06, this rule did not expire on 7-21-14 since it was extended pursuant to RSA 541-A:14-a until replaced by He-W 806.89 in Document #10743, effective 12-12-14.

 

          He-W 806.01 - 806.17 and He-W 806.19 through He-W 806.36  RESERVED

 

He-W 806.18  Institutional Residence.

 

(a)  The department of health and human services (DHHS) shall verify institutional residence and the individual's status within the institution by written or verbal contact with the institution.

 

(b)  Individuals who received medical assistance but whose assistance was terminated at the time of admission to New Hampshire Hospital (NHH) shall have medical assistance redetermined pursuant to He-W 684.01 without a personal interview, as defined in He-W 601.06(l), if the individual meets the criteria in (c) below.

 

          (c)  A personal interview shall not be required of individuals described in (b) above when the individual:

 

(1)  Is discharged within 60 days from the date of admission; and

 

(2)  Provides to DHHS all of the following information in writing:

 

a.  Individual’s name, case number, discharge address, and indication of whether the individual received medical assistance prior to admission to NHH;

 

b.  Date of admission to and discharge from NHH;

 

c.  Shelter costs for the non-adult categories of medical assistance;

 

d.  Assistance group composition of all people that will reside at the discharge address with the individual, and their relationship to the individual;

 

e.  Current income of the individual and all household members;

 

f. Current resources, pursuant to He-W 601.07(f), of the individual and all household members;

 

g. Amount and type of any third-party medical coverage held by the individual and all household members;

 

h. Any other changes in or information about case circumstances that would impact eligibility; and

 

i.  Individual’s or representative’s dated signature acknowledging:

 

1. That the individual has reported all changes that have occurred since the individual’s last eligibility determination and that the information provided to DHHS is true and complete to the best of his or her knowledge;

 

2.  That the individual must provide proof of all statements and information provided to DHHS, and that the individual’s or representative’s signature gives permission to DHHS to contact other persons or organizations to get additional proofs of the individual’s eligibility;

 

3.  That any person who intentionally makes a false statement or misrepresents his or her circumstances or intentionally fails to disclose the receipt of property, wages, income, or resources, or any changes in circumstances that would affect his or her initial or continued eligibility for assistance may be found guilty of violating state law;

 

4.  That the individual must report any changes in circumstances within 10 calendar days of when the change occurs, or as instructed by DHHS, pursuant to RSA 167:17; and

 

5. That if the individual is not satisfied with any decision made by DHHS, the individual may request an appeal within 30 calendar days from the date of the notice; and

 

(3)  Provides to DHHS documentation of changes in address, shelter costs for the non-adult categories of medical assistance, assistance group composition, income, resources, and medical coverage that have occurred since the last eligibility determination, within 10 calendar days of the date of the request.

 

(d)  A personal interview shall be required to redetermine medical assistance for individuals released from an institution when:

 

(1)  An eligibility redetermination was due or overdue when the individual was admitted to New Hampshire Hospital;

 

(2)  An eligibility redetermination is due during the month the individual is discharged from New Hampshire Hospital;

 

(3)  DHHS determines that the individual failed or refused to cooperate without good cause pursuant to He-W 601.04(i) with the medical review process pursuant to He-W 685.01; or

 

(4)  The individual does not meet the criteria described in (c) above.

 

Source.  #11042, eff 2-24-16

 

          He-W 806.37  Application for Disability Benefits.  In accordance with He-W 652.07(b)(5),  the applicant or recipient  shall provide a letter from the Social Security Administration or provide a form designated by the Social Security Administration acknowledging the individual has applied for disability benefits under 42 USC 401-434 or 42 USC 1381-1383f.

 

Source.  #11026, eff 1-23-16

 

          He-W 806.38 - 806.54  RESERVED

 

          He-W 806.55  Deemed Income.  Income deemed from a parent or legal guardian to a minor casehead, when the casehead lives with the parent or legal guardian, shall be verified in the same manner as income of an adult category assistance group member, unless otherwise designated.

 

          He-W 806.56 to He-W 06.59  RESERVED

 

Source.  #13414, eff 7-26-22

 

          He-W 806.60  Verification of Educational Income - Adult Categories.  Acceptable verification of specific types of educational income shall be provided to the department, as follows:

 

          (a)  For U.S. Secretary of Education scholarships and grants:

 

(1)  Written or verbal contact with the financial aid officer at the individual's school; or

 

(2)  A letter of award;

 

          (b)  For work/study income:

(1)  Written or verbal contact with the financial aid officer at the individual's school;

 

(2)  Written or verbal contact with the individual’s employer to obtain earnings information; or

 

(3)  Pay stubs;

 

          (c)  For other post-graduate scholarships or grants:

 

(1)  Written or verbal contact with the financial aid officer at the individual's school; or

 

(2)  A letter of award;

 

          (d)  For veterans' educational assistance benefits:

 

(1)  A written or verbal statement from the Department of Veterans Affairs;

 

(2)  A letter of award which states the amount and that benefits are contingent upon regular school attendance; or

 

(3)  A check or check stub to verify the amount; and

 

          (e)  For student loans:

 

(1)  Written or verbal contact with the financial aid officer at the individual's school; or

 

(2)  A loan agreement or other loan document.

 

Source.  #10699, eff 10-24-14

 

          He-W 806.61 through He-W 806.67  RESERVED

 

          He-W 806.68  Adult OAA, APTD, and ANB Employment Expense Disregard.

 

(a)  Verification of employment expenses shall not be required for use in the cost of care computation for OAA, APTD, or ANB applicants and recipients requesting nursing facility, choices for independence (CFI), home and community-based care for the developmentally disabled (HCBC-DD), home and community-based care for individuals with an acquired brain disorder (HCBC-ABD), and home and community-based care for in-home supports (HCBC-IHS) assistance, if the individual's claimed monthly employment expenses are $18.00 or less.

 

(b)  Acceptable verification of the amount of employment expenses for use in the cost of care computation for OAA, APTD or ANB applicants and recipients requesting nursing facility, CFI, HCBC-DD, HCBC-ABD, and HCBC-IHS assistance, shall be:

 

(1)  For social security taxes, pay stubs, a letter or other written information from the employer which specifies the amount of social security taxes withheld from earnings;

 

(2)  For railroad retirement, pay stubs or a letter from the employer verifying the employment expense;

 

(3)  For federal withholding:

 

a.  Pay stubs or a letter from the employer verifying the employment expense; or

 

b. For self-employed individuals, IRS tax forms or other documents which indicate the amount of federal withholding taxes being paid;

 

(4)  For transportation costs:

 

a.  A statement signed by the individual indicating whether reimbursement is received and the amount and source of the reimbursement;

 

b.  If child care related transportation costs are claimed, a statement signed by the child care provider attesting to the fact that it is necessary for the individual to provide the child's transportation;

 

c.  If the individual's own vehicle is used, a signed statement indicating the number of miles claimed and that such mileage is the shortest necessary to travel to and from work;

 

d.  If the individual rides in another person's privately owned vehicle, the documentation in c. above, and a statement signed by the driver which indicates the amount and frequency of the charge for transportation; or

 

e.  If the individual uses public transportation, a statement signed by the provider of the transportation which indicates the amount normally charged to the public and whether the charge is for one-way or round-trip;

 

(5)  For special clothing, paid receipts for purchased clothing which substantiate that the costs are recurring; and

 

(6)  For child care costs:

 

a.  If the individual is being reimbursed for child care costs through the department of health and human services (DHHS) child care assistance program, the amount, if any, of the child care fee which the client must pay as shown on the DHHS invoice; or

 

b.  If there is no DHHS child care assistance program involvement with child care costs, acceptable documentation shall be:

 

1.  A statement signed by the individual indicating whether reimbursement is received and the amount and source of the reimbursement;

 

2.  A written statement signed by the child care provider indicating the amount and frequency of the child care cost; or

 

3.  DHHS verbal contact with the child care provider indicating the amount and frequency of the child care cost.

 

(c)  If the individual fails or refuses to provide verification of a claimed expense, the amount of the unverified expense shall not be an allowable employment expense.

 

Source.  #11026, eff 1-23-16

 

He-W 806.69  Impairment Related Work Expenses.

 

(a)  When claiming impairment related work expenses (IRWE’s), APTD applicants and recipients shall furnish the department of health and human services (DHHS) with documentation of the need for and the unreimbursed cost of one or more of the IRWE’s described in 20 CFR 416.976.

 

(b)  Acceptable documentation of the need for IRWE’s shall be a signed statement from a physician, psychologist, vocational rehabilitation counselor, or other medical health professional which:

 

(1)  Indicates that the expense is related to the applicant or recipient’s impairment and is necessary for employment; and

 

(2)  Is dated within 30 days of the date that the documentation is provided to DHHS.

 

(c)  Acceptable documentation of the unreimbursed cost of the expense shall be a paid receipt, canceled check or other documentation that demonstrates that the applicant or recipient has paid for the item or service out of his or her own funds, and has not and will not be reimbursed for the expense.

 

(d)  For an applicant or recipient wishing to claim mileage expenses for his or her specially equipped vehicle, the applicant or recipient shall provide documentation of:

 

(1)  The ownership, make, and model of the vehicle;

 

(2)  The specific modifications that were made to the vehicle; and

 

(3)  The number of miles traveled to and from work.

 

(e)  Refusal or failure to provide verification of an IRWE shall result in the expense not being allowed as a deduction from earned income.

 

(f)  OAA recipients with an IRWE deduction at the time their case is transferred from APTD to OAA shall furnish documentation pursuant to (a) above.

 

Source.  #11026, eff 1-23-16

 

          He-W 806.70 through He-W 806.73  RESERVED

 

He-W 806.74  Allowable Deductions.

 

(a)  Acceptable verification of allowable deduction amounts for medical assistance programs that do not determine income pursuant to 42 CFR 435.603 shall include:

 

(1)  For training expenses:

 

a.  The same documentary evidence required under He-W 606.68 for transportation costs, special clothing, child care costs, and other allowable expenses; and

 

b.  A letter from an official of the training program which states that the expense is required and a receipt or other verification showing the amount which is required to be paid for the expense;

 

(2)  For court-ordered child support, a copy of the most current court order;

 

(3)  For court-ordered alimony, a copy of the most current court order;

 

(4)  For garnishments, a letter from the employer; and

 

(5)  For incurred current medical expenses and prior medical debts of an individual residing in a nursing facility:

 

a.  Provider bills, reminder notices and collection agency notices which are dated within 30 days of the month to which the debt is expected to be applied;

 

b.  A statement from the insurance company of the intent to pay covered charges, as indicated by an explanation of medical benefit;

 

c.  The medical service provider's bill showing insurance payment;

 

d.  District office collateral verification by letter or telephone with the insurance or medical provider of the charges and allowances toward medical services; or

 

e.  Historical data previously known to the district office which documents the amount of the charges and allowances toward recurring medical services.

 

(b)  For all medical assistance programs, if the individual refuses or fails to provide verification of a claimed expense, the amount of the unverified expense shall not be considered an allowable deduction.

 

Source.  #10895, eff 7-22-15

 

          He-W 806.75 through He-W 806.77 - RESERVED

 

          He-W 806.78  Personal Property Resources.

 

          (a)  For medical assistance categories that have a resource test:

 

(1)  The following documents shall be used to verify that a resource is legally unavailable to the applicant or recipient:

 

a.  For irrevocable trust funds, the trust instrument or agreement;

 

b.  For irrevocable burial funds, the bank account, agreement, trust instrument, or similar document which clearly states that the burial funds are not legally available to the individual; and

 

c.  For property in probate, written or verbal contact with the register of probate in the appropriate county indicating that the property is currently in probate and legally unavailable to the applicant or recipient or a letter from the attorney handling the property indicating the property is legally unavailable to the applicant or recipient;

 

(2)  Acceptable verification of income tax refunds or lump sum earned income tax credit payments shall be a copy of the tax refund check or the applicant’s or recipient’s submitted tax return;

 

(3)  Acceptable verification of the value of IRA and non-contractual Keogh accounts and penalty for early withdrawal shall be a written statement from the financial institution where the account was issued indicating the current balance in the account and penalty for withdrawal of the entire amount in the account;

 

(4)  Acceptable verification of the type of Keogh account, such as contractual or non-contractual, shall be a written statement from the individual's employer or the financial institution where the account was issued indicating whether it involves a contractual relationship with other individuals and if money can be withdrawn without affecting the other individuals involved;

 

(5)  Acceptable verification of the face value of life insurance shall be:

 

a.  The actual policy itself; or

 

b.  Written or verbal contact with the insurance company when the face value cannot be determined using the actual policy;

 

(6)  Acceptable verification of the equity value of life insurance shall be determined by written or verbal contact with the insurance company;

 

a.  Using the cash value or non-forfeiture of benefits table, if there is no loan on the policy; or

 

b.  Written or verbal contact with the insurance company, if there is a loan on the policy;

 

(7)  Acceptable verification of lump sum death benefits shall be a letter of award, written contact with the agency providing the benefit or with the funeral director arranging for payment of the benefit, or if written documentation cannot be furnished, department of health and human services (DHHS) verbal contact with the agency or funeral director;

 

(8)  Acceptable verification of resources resulting from an accumulation of types of income which are excluded by federal mandate shall be letters of award, written statements from the source providing benefits, or, if written documentation cannot be furnished, DHHS verbal contact with the source providing the benefits;

 

(9)  Acceptable verification of stocks and bonds shall be the market value of the stock or bond in the financial section of a current newspaper or, if written documentation cannot be located, DHHS verbal contact with a stock broker; and

 

(10)  Good faith effort to sell a personal property asset that cannot be readily converted to cash shall be newspaper clippings or evidence of other means of advertising showing that the asset is for sale at a price commensurate with the property’s fair market value.

 

(b)  For verification of resources for medical assistance categories that have a resource test, the following shall apply:

 

(1)  For equity value of a vehicle:

 

a.  The fair market value of an automobile or truck shall be verified by using the “trade-in value” in the most recent edition of the NADA Official Used Car Guide, also known as the “Blue Book”;

 

b.  The fair market value shall not be increased because of special equipment for the handicapped, low mileage, or optional equipment;

 

c.  If the applicant or recipient states that the fair market value in the Blue Book does not apply to the vehicle because of body damage or other factors, the individual shall present verification of the true fair market value of the vehicle from an auto dealer or an individual who is engaged in a vehicle sales or service business; and

 

d.  If a vehicle is custom made, too old, or too new to be included in the Blue Book, the applicant or recipient shall verify its fair market value by:

 

1.  Obtaining an appraisal from an automobile dealer or an individual who is engaged in a vehicle sales or service business;

 

2.  Submitting a tax assessment on the vehicle indicating its value; or

 

3.  Submitting a newspaper advertisement which indicates the amount for which like vehicles are being sold;

 

(2)  The applicant’s or recipient’s written statement shall be acceptable verification of the fact that a vehicle is a junk vehicle, provided the statement gives an accurate and complete description of the vehicle's condition; and

 

(3)  Acceptable verification of the fact that farm machinery and vehicles are necessary for subsistence, maintenance, or employment shall be a written statement from the applicant or recipient.

 

(c)  Acceptable verification of incurred unpaid medical expenses for medical assistance shall be bills which substantiate the amount of unpaid medical expenses that the applicant or spouse have incurred and that the applicant or spouse is still liable for the unpaid medical expenses.

 

Source.  #11141, eff 7-22-16

 

          He-W 806.79 –through He-W 806.88  RESERVED

 

          He-W 806.89  Verification Requirements for In and Out Medically Needy Medical Assistance.

 

          (a)  When requested to do so by the department in accordance with He-W 878.01, the client shall provide documentation of the following:

 

(1)  Incurred current medical expenses and obligated prior medical debts, including those of individuals of a family, as defined in He-W 601.04(c), or family members, as defined in He-W 601.04(f), who reside in the same living unit as the client or for whom the client is liable;

 

(2)  Medical services and amounts that are subject to third party reimbursement or insurance coverage; and

 

(3) The relationship between the client and the individual for whom medical expenses are claimed.

 

          (b)  Acceptable documentation of the above criteria shall include, but not be limited to:

 

(1)  Provider bills, reminder notices and collection agency notices which are dated within 30 days of the month to which the debt is expected to be applied;

 

(2)  A statement from the insurance company of the intent to pay covered charges, or the medical service provider's bill showing insurance payment;

 

(3)  Department collateral verification by letter or telephone with the insurance or medical provider of the charges and allowances toward medical services;

 

(4)  Historical data previously received by the department which documents the amount of the charges and allowances toward recurring medical services; and

 

(5)  A birth certificate, baptismal record, marriage certificate, or other document that establishes the relationship between the client and the individual for whom medical expenses are claimed.

 

Source.  (See Revision Note #1 at Chapter heading for He-W 600) #5171, eff 6-26-91; ss by #5508, eff 12-1-92; ss by #6865, eff 10-3-98; ss by #8684, eff 7-21-06; ss by #10743, eff 12-12-14 (See Revision Note at Part heading for He-W 806)

 

          He-W 806.90 –through He-W 806.91  RESERVED

 

          He-W 806.92  Telephone Redetermination.

 

          (a)  Current recipients of any program of assistance except for medical assistance as described in He-W 858.05 and He-W 858.06, who reapply for assistance via the telephone, shall be considered to have requested a redetermination as described in He-W 684.01(a).

 

          (b)  The telephone redetermination process pursuant to (a) above shall only be available as funding and resources within the current state fiscal year are available.

 

          (c)  All general, categorical, technical, and financial requirements that apply when eligibility for assistance is redetermined whether based on federal or state law, federal regulation, or published department rules, shall apply when an individual requests a redetermination pursuant to (a) above.

 

Source.  #12714, eff 1-23-19

 

PARTS He-W 807 through He-W 815

 

            He-W 816.02  Eligibility of Qualified Aliens. As long as all other eligibility requirements are met, medical assistance shall be provided to qualified aliens as defined in 8 USC 1641(b), under the following conditions:

 

            (a)  The qualified alien entered the United States with a status within the meaning of the term “qualified alien” before August 22, 1996; or

 

            (b)  For qualified aliens who enter the United States on or after August 22, 1996, a period of 5 years has elapsed since the date of the alien’s entry into the United States with a status within the meaning of the term “qualified alien.”

Source.  #13526, EFF 1-24-23

 

PARTS He-W 817 through He-W 819 RESERVED

 

PART He-W 820  ASSET TRANSFERS

 

He-W 820.01  Purpose.  These rules describe the treatment of transfers of assets.  When an individual applies for or receives nursing facility (NF), medical assistance or any category of home and community based care (HCBC) waiver services, the department of health and human services (DHHS) will use these rules to determine if that individual transferred, assigned, or disposed of the ownership of an asset within the look back period in accordance with 42 USC 1396p(c).

 

Source.  #12217, eff 6-22-17

 

          He-W 820.02  Definitions.  As used in this section, the following terms shall have the meanings indicated:

 

          (a)  “Assets” means “assets” as defined in 42 USC 1396p(h)(1), that is, all income and resources of the individual and of the individual’s spouse.  The term includes any income or resources to which the individual or the individual’s spouse is entitled but does not receive because of any action by the individual, the individual’s spouse, or a person, including a court, or administrative body with legal authority to act in place of or on behalf of the individual, or the individual’s spouse, or any person, including a court or administrative body, acting at the direction or upon the request of the individual, or the individual’s spouse.

 

(b)  “Fair market value” means the current market value of an asset at the time the asset is transferred.  The current market value is the selling price for which it can reasonably be expected to sell on the open market in the geographic area involved.

 

(c)  “Home and community based care (HCBC)” means community services that individuals might need in order to prevent institutionalization as described under subsection (c) or (d) of Section 1915 of the Social Security Act.

 

(d)  “Income” means “income” as described in 42 USC 1382a of the Social Security Act. The term includes both earned and unearned income.

 

(e)  “Institution” means a hospital, nursing facility, intermediate care facility for individuals with intellectual disabilities, or any other provider which is an institution as defined by 42 CFR 435.1010.

 

(f)  “Institutionalized individual” means any individual who is an inpatient in a nursing facility, including an intermediate care facility for individuals with intellectual disabilities, or who is an in-patient in a medical facility and is receiving a level of care provided in a nursing facility, or who is receiving care, services, or supplies pursuant to a waiver under subsection (c) or (d) of Section 1915 of the Social Security Act.

 

(g)  “Penalty period” means the period of time in which an individual is ineligible for institutional or HCBC waiver services due to a transfer of an asset for less than fair market value.

 

(h)  “Resources” means “resources” as described in 42 USC 1382b of the Social Security Act, except for, in the case of an institutionalized individual,  the homestead exclusion provided for in subsection (a)(1) of that section.

 

(i)  “Transfer” means any action or failure to act which has the effect of changing an ownership interest in an asset from the individual to another person, or preventing an ownership interest the individual would have otherwise enjoyed.  A transfer includes any direct or indirect method of disposing of an interest in an asset.

 

(j)  “Unearned income” means all contributions, payments, pensions, benefits, loans, awards, or other income which is not received as compensation for work performed.

 

          (k)  “Valuable consideration” means that an individual received in exchange for his or her right or interest in an asset some act, object, service, or other benefit which is tangible and has intrinsic value to the individual that is roughly equivalent to or greater than the value of the transferred asset.

 

Source.  #12217, eff 6-22-17

 

He-W 820.03  Asset Transfers.

 

(a)  Asset transfers described in this rule shall:

 

(1)  Be in addition to and shall not supersede transfers described in 42 USC 1396p(c)(2)(A), (B), (C), and (D);

 

(2)  Include every type of income and resource, unless otherwise noted in this rule; and

 

(3)  Apply to transfers made by:

 

a. Individuals applying for or receiving nursing facility (NF) medical assistance or any category of HCBC services furnished under a waiver granted under 42 USC 1396n(c), pursuant to He-W 856.01(d); and

 

b.  The individual’s spouse.

 

(b)  Pursuant to 42 USC 1396p(c)(2)(A)(iv), DHHS shall not penalize the transfer of an individual’s primary residence to his or her child if the child resided in the individual’s home for a period of at least 2 years immediately before the date the individual became an institutionalized individual, and the child provided care to such individual which permitted such individual to reside at home on a continuous basis rather than in such an institution or facility.

 

(c)  The individual in paragraph (b) shall provide the following verifications:

 

(1)  At least one letter signed by a medical professional who cared for the individual prior to admission to the medical institution stating that the child provided the kind and quality of care necessary to maintain the individual at home rather than in a medical institution for at least 2 years immediately before the individual’s admission to the medical institution;

 

(2)  A statement from the child describing the type or level of care provided; and

 

(3)  Medical records consistent with the information described in (b) above.

 

          (d)  Pursuant to RSA 167:4, I(b) and 42 USC 1396p(c)(1),  a transfer of assets shall be considered to have been made if, within 60 months prior to the date of application or at any time while receiving NF medical assistance or any category of HCBC waiver services, the individual or the individual’s spouse:

 

(1)  Takes action that reduces or eliminates an individual's ownership or control of such assets;

 

(2)  Gives another person access to the asset through joint ownership and any action is taken, either by the individual or by any other person, that reduces or eliminates such individual's ownership;

 

(3)  Executes an instrument to transfer title of an asset to another person at a future date and delivers the instrument to the person who is to receive title;

 

(4)  Transfers title or ownership of the individual’s home, or its associated land, to another person or entity;

 

(5)  Transfers title of real property, including income-producing real property;

 

(6)  Transfers assets into an irrevocable trust or similar legal device, from which no payment could under any circumstances be made to the individual;

 

(7)  Obtains a reverse mortgage, a home equity conversion mortgage, or a similar loan on  any home or other real property and transfers the proceeds to another person;

 

(8)  Is entitled to an asset but does not receive the asset because of action:

 

a.  By the individual or the individual's spouse;

 

b.  By a person, including a court or administrative body, with legal authority to act in place of or on behalf of the individual or such individual's spouse; or

 

c.  By any person, including any court or administrative body, acting at the direction or upon the request of the individual or such individual's spouse;

 

(9)  Purchases a promissory note, loan, or mortgage, unless such note, loan, or mortgage:

 

a.  Provides a repayment term that is actuarially sound pursuant to (j)(3) below;

 

b.  Provides for payments to be made in equal amounts during the term of the loan with no deferral and no balloon payments; and

 

c.  Prohibits the cancellation of the balance upon the death of the lender; or

 

(10)  Purchases a life estate interest in another individual’s home, unless they have resided in the home for a period of at least one year after the date of the purchase.

 

(e)  Actions by the individual or the individual’s spouse which would cause income or resources not to be received shall include but not be limited to:

 

(1)  Irrevocably waiving pension income or any other form of income;

 

(2)  Waiving an inheritance;

 

(3)  Not accepting or accessing injury settlements, judgments, or court awards;

 

(4)  Diverting of tort settlements by the defendant into a trust or similar device to be held for the benefit of the plaintiff; or

 

(5)  Refusal to take legal action to obtain a court ordered payment that is not being paid, such as child support or alimony, unless the individual is being, has been, or is at risk of being, battered or subjected to extreme cruelty as described in 42 USC 608(a)(7)(c) and  corroboration is provided by the documentation described below including a:

 

a.  Court, medical, criminal, child protective services, psychological, or law enforcement record, or a statement from a social service provider;

 

b.  Written statement from a social worker from a public or private social service agency; or

 

c.  Sworn statements from an individual with knowledge of the circumstances.

 

(f)  For individuals applying for or receiving medical assistance, the department of health and human services (DHHS) shall evaluate asset transfers to determine if the individual derived fair market value, as defined in He-W 820.02(b) above, from the transfer.

 

(g)  DHHS shall evaluate the transfer to determine if the individual derived fair market value, as defined in He-W 820.02(b) above, whenever an individual applying for or receiving medical assistance has transferred, assigned or disposed of title or ownership of an otherwise excluded home to another individual or entity.

 

(h)  Asset transfers from which the individual receives fair market value or other valuable consideration shall require no further evaluation for asset transfer.

 

(i)  A transfer of assets for love and consideration, or which is made for similar reasons, shall not be considered to be a transfer for fair market value.

 

(j)  A transfer of assets to a relative for care provided in the past shall not be a transfer for fair market value.  Although relatives may be legitimately paid for providing care, any services provided for free in the past shall be assumed to have been intended to have been provided without compensation unless it can be rebutted with tangible evidence that a compensation arrangement had been agreed to in writing at the time services were provided.

 

(k)  When determining whether an individual has received fair market value for a transfer when a life estate has been established, DHHS shall:

 

(1)  Determine what the fair market value of the asset was at the time of transfer;

 

(2)  Take into account the individual’s age at the time of the transfer; and

 

(3)  Calculate the value of the life estate using the life estate tables found in the Supplemental Security Income (SSI) Program Operations Manual System (POMS), section SI 01140.120 as follows:

 

a.  The life estate value shall be established by multiplying the market value of the asset by the life estate factor that corresponds to the individual’s age at the time of the transfer;

 

b.  The value of the life estate shall be subtracted from the value of the asset transferred; and

 

c.  The difference between the value of the life estate and the amount the individual was reimbursed for the remainder interest shall be the portion of the asset transferred for less than fair market value.

 

(l)  When determining whether an individual or spouse has received fair market value for a transfer of assets into an annuity, DHHS shall:

 

(1)  Determine the fair market value of the asset at the time of transfer into the annuity;

 

(2)  Determine if the expected return on the annuity is commensurate with a reasonable estimate of the life expectancy of the beneficiary to determine whether the annuity is actuarially sound;

 

(3)  Use the life expectancy tables published by the office of the chief actuary of the social security administration, pursuant to 42 USC 1396p(c)(1)(G)(ii)(II);

 

(4)  Determine that the individual has received fair market value for the annuity if the average number of years of expected life remaining for the individual coincides or exceeds the life of the annuity; and

 

(5)  Determine that the individual did not receive fair market value for the annuity if the average number of years of expected life remaining for the individual is less than the life of the annuity.

 

(m)  The background information of the asset transfer shall be evaluated further to determine if assets might have been transferred for purposes of qualifying for medical assistance if DHHS determines that the individual did not receive fair market value from the transfer.

 

(n)  Factors to be evaluated in assessing asset transfers referred to in (l), shall include:

 

(1)  Timeframes between the transfer of assets and the date of application;

 

(2)  The individual's health at the time of the transfer; and

 

(3)  The individual's economic situation at the time of the transfer.

 

(o)  The transfer shall be considered questionable if the evaluation of background information of the transfer suggests that the individual transferred assets for purposes of qualifying for medical assistance or results in qualifying earlier than otherwise would have been possible if the individual had retained all of the asset(s).

 

(p)  The individual shall provide additional information and documentation to DHHS upon request to demonstrate that assets were not transferred for purposes of qualifying for medical assistance, if the transfer is considered questionable.

 

(q)  Reasons for transferring assets for purposes other than qualifying for medical assistance shall include:

 

(1)  The individual transferred the asset to prevent foreclosure or sale of the asset by the lien holder, thus preventing total loss of the asset;

 

(2)  The individual transferred the asset for self-support because the individual's income and resources were insufficient to meet basic needs or to maintain upkeep of the asset, such as taxes and repairs, and the individual's basic needs were provided for in return for the transfer, or the individual lived off the proceeds of the asset;

 

(3)  The individual transferred the asset to meet the terms of a written agreement, including debts arising from such agreement;

 

(4)  The individual transferred the asset to meet the terms of an oral agreement, including debts arising from such agreement;

 

(5)  The individual is not able to afford to take the necessary action to obtain the asset or the cost of obtaining the asset is greater than the asset is worth, resulting in a case of failure to cause assets to be received; or

 

(6)  The individual is being, has been, or is at risk of being battered or subjected to extreme cruelty as described in 42 USC 608(a)(7)(c) and as corroborated by the documentation described He-W 820.01(d)(5).

 

(r)  The burden of proof for substantiating the fact that assets were not transferred for purposes of qualifying for medical assistance shall rest with the individual.

 

(s)  If the individual refuses or fails to prove that assets were not transferred for purposes of qualifying for medical assistance, DHHS shall determine that the assets were transferred for the purposes of qualifying for medical assistance and the individual shall be ineligible pursuant to (s) below for the following institutionalized care:

 

(1)  Nursing facility services;

 

(2)  A level of care in any institution equivalent to that of nursing facility services; and

 

(3)  HCBC furnished under a waiver granted under 42 USC 1396n(c).

 

(t)  To determine the number of months of ineligibility for the services described in (r) above for an individual who has transferred property for purposes of qualifying for medical assistance the following methodologies shall be used:

 

(1)  The penalty period start date for all individuals who transfer assets for less than fair market value to make themselves eligible for medical assistance as of February 8, 2006, shall be whichever is later:

 

a.  The first day the individual met all other eligibility criteria and would be eligible but for the transfer, provided that the date does not occur during an existing penalty period as described in (4) below; or

 

b.  The first day of a month after which assets have been transferred provided that the date does not occur during an existing penalty period as described in (4) below;

 

(2)  When an individual or an individual’s spouse makes multiple fractional transfers of assets in more than one month for less than fair market value, the penalty shall be based on the total cumulative uncompensated value of all such transfers, pursuant to 42 USC 1396p(c)(1);

 

(3)  The penalty period shall be based solely on the value of the assets transferred;

 

(4)  When a countable transfer takes place during an existing penalty period, a new penalty period shall not begin until the existing penalty period has expired;

 

(5)  When an individual makes a series of transfers within one month, the total value of the individual transfers for the month shall be used to calculate the penalty;

 

(6)  The penalty period shall be the number of months equal to:

 

a.  The uncompensated value of assets transferred by the individual, divided by the average statewide monthly nursing facility private rate; and

 

b.  The average statewide daily nursing facility rate shall be established by dividing the average statewide monthly nursing facility private rate, as determined and updated annually by the division's bureau of audits and rate setting, by 30.42;

 

(7)  When the penalty period consists of any number of full months and a partial month, the partial month penalty period shall apply in accordance with (9) below;

 

(8)  When the amount of the transfer is less than the average statewide monthly nursing facility private rate, a partial month penalty shall apply;

 

(9) To determine the number of days the partial month penalty shall be in effect, the uncompensated value of assets transferred by the individual shall be divided by the average daily nursing facility rate described in (6)b. above;

 

(10)  When assets have been transferred so that the penalty periods overlap, the individual penalty periods shall be calculated and imposed sequentially;

 

(11)  When multiple transfers are made in such a way that the penalty period for each transfer will not overlap, each transfer shall be treated as a separate event, each with its own penalty period;

 

(12)  When a spouse of an individual transfers an asset that results in a penalty for the individual, the penalty period shall be apportioned between the spouses when:

 

a.  The spouse either is, or becomes, eligible for medical assistance;

 

b.  A penalty could be assessed against the spouse; and

 

c. Some portion of the penalty against the individual remains at the time the above conditions are met;

 

(13)  When the penalty period for an individual is interrupted due to the death of the individual or  the individual’s discharge from institutionalized care, the remaining penalty period in (12) above, which is applicable to both spouses shall be served by the remaining spouse; and

 

(14)  A penalty period imposed for a transfer of assets shall run continuously from the first date of the penalty period, regardless of whether the individual remains institutionalized.

 

(u)  A penalty shall not be assessed for transfers of assets for less than fair market value under any of the following circumstances:

 

(1)  The individual intended, and attempted to dispose of the asset either at fair market value or for other valuable consideration, and circumstances caused the individual to transfer the asset for less than fair market value;

 

(2)  The individual transferred the assets for a purpose other than to qualify for medical assistance; or

 

(3)  All of the assets transferred for less than fair market value have been returned to the individual.

 

(w)  Individuals claiming that circumstances caused the asset to be transferred for less than fair market value pursuant to (u)(1) above, shall provide documentation of:

 

(1)  The individual’s attempt to dispose of the asset at fair market value, or for other valuable consideration; and

 

(2)  The value at which the asset was disposed.

 

(x)  Individuals claiming that assets were transferred for a purpose other than to qualify for medical assistance pursuant to (u)(2) above, shall provide documentation of:

 

(1)  The specific purpose for which the asset was transferred; and

 

(2)  The reason it was necessary to transfer the asset for less than fair market value or other valuable consideration.

 

(y)  If a penalty was assessed for transferring an asset for less than fair market value or other valuable consideration and the asset was returned to the individual, then DHHS shall:

 

(1)  Generate a retroactive adjustment back to the beginning of the penalty period if the individual met all other eligibility criteria; or

 

(2)  Redetermine the penalty period pursuant to (s) above, when only part of an asset, or its equivalent value, has been returned.

 

(z)  Asset transfer penalties shall not be imposed due to undue hardship pursuant to RSA 167:4, III-a and 42 USC 1396p(c)(2)(D).

 

Source.  #12217, eff 6-22-17

 

PART He-W 821  TECHNICAL REQUIREMENTS FOR NURSING FACILITY (NF) AND HOME AND COMMUNITY BASED CARE (HCBC) SERVICES

 

Revision Note:

 

          Document #12217, effective 6-22-17, readopted with amendments He-W 621 titled “Technical Requirements for Nursing Facilities (NF) and Home and Community Based Care (HCHC) Services” and renumbered the rule as He-W 821 titled “Technical Requirements for Nursing Facility (NF) and Home and Community Based Care (HCHC) Services”.  The source note information for the rules He-W 821.01 through He-W 821.03 in He-W 821 prior to Document #12217 includes the documents filed under He-W 621.01 through He-W 621.03, respectively.

 

He-W 821.01  Asset Transfer Penalty Undue Hardship Waiver.

 

(a)  As used in this section, the following terms shall have the meanings indicated:

 

(1)  “Discharge” means “discharge” as defined in RSA 151:19, I-a, namely, the “movement of a patient from a facility to a non-institutional setting or the termination of services by a home health care provider when the discharging facility or home health care provider ceases to be legally responsible for the care of the patient”;

 

(2)  “Good cause” means any circumstance beyond a person’s control that prevents that person from complying with a requirement, including:

 

a.  A death in the person’s immediate family;

 

b.  Personal injury or serious illness of the person or an immediate family member; or

 

c.  Another compelling reason or justification;

 

(3)  “Individual” means the person who applied for or is receiving services from the nursing facility (NF) or under the home and community based (HCBC) waiver program.

 

(4)  “Necessities of life” means those things a person needs to live, including but not limited to, heat, hot water, electricity, gas service, or cooking fuel;

 

(5)  “Sworn statement” means a statement made under oath or affirmation reciting facts which are personally known by the signer, and which are sworn to or affirmed and notarized by either a notary public or justice of the peace; and

 

(6)  “Undue hardship” means a hardship that imposes an unreasonable or disproportionate burden on the individual, as described in RSA 167:4, III-a, and 42 USC 1396p(c)(2)(D).

 

(b)  Requests for an asset transfer penalty undue hardship waiver shall include all of the following:

 

(1)  The individual’s name, address, and telephone number;

 

(2)  The name, address, telephone number, and relationship to the individual, of the individual’s legal guardian, authorized representative (AR), power-of-attorney, or attorney, if any;

 

(3)  Identification of the specific reason(s) for the request for an asset transfer penalty undue hardship waiver from the following list:

 

a.  The asset was transferred by a person representing the individual and it can be demonstrated that the individual lacked the mental capacity to comprehend the disqualifying nature of the transfer;

 

b.  The application of the asset transfer penalty would result in the individual being deprived of, and otherwise unable to obtain, necessary care such that the individual’s health or life would be endangered; and

 

c.  The application of the asset transfer penalty would result in the individual being deprived of, and otherwise unable to obtain, food, clothing, shelter, and/or other necessities of life; and

 

(4)  The printed name and dated signature of the individual, or, if filed by the individual’s agent or representative, the printed name and dated signature of the agent or representative, and their relationship to the individual.

 

(c)  A request for an asset transfer penalty undue hardship waiver shall include the following attachments:

 

(1) If the request for an undue hardship waiver was filed by the individual’s agent or representative, a copy of the legal documentation shall be provided that authorizes the agent or representative to act on behalf of the individual, such as an authorized representative declaration, court order appointing a guardian, power of attorney, etc.;

 

(2)  The following verifications shall be required in all cases in the form of written documentation or other evidence that a good faith effort was made to recover the asset(s) transferred or to make the asset(s) available to the individual, such as, but not limited to:

 

a.  Any written request for the asset(s) to be returned to the individual;

 

b.  Any demand letter(s);

 

c.  Any response letter(s) from any recipient of the transferred asset(s);

 

d.  Any documents or other evidence showing that legal action has been initiated to recover the asset(s); or

 

e.  Any document or other evidence that demonstrates that action has been taken to recover the asset(s) or to make the asset(s) available to the individual to help pay for the cost of the individual’s stay in the NF or to pay for HCBC services;

 

(3)  The following verifications shall be required if the request for an asset transfer penalty undue hardship waiver is based upon a claim that the individual lacked the mental capacity to comprehend the disqualifying nature of the transfer, pursuant to (b)(3)a. above:

 

a.  A written, dated, and signed statement from a licensed physician stating that the individual was mentally incapacitated at the time of the transfer, along with supporting medical records or an order of findings from a probate court concerning the individual’s competency at the time of the transfer; and

 

b.  Financial records that demonstrate that the asset(s) was transferred by the individual’s agent or representative.

 

(4)  The following verifications are required if the request for an asset transfer penalty undue hardship waiver is based upon a claim that the individual’s health or life will be endangered pursuant to (b)(3)b. above:

 

a.  For NF services:

 

1.  A dated and signed statement from the NF that documents:

 

(i)  The individual is currently residing in the NF;

 

(ii)  The individual’s current arrearage owed to the NF; and

 

(iii)  The monthly amount currently being paid to the NF by the individual;

 

2.  A sworn, signed, and dated statement from the individual or the individual’s agent or representative that documents:

 

(i)  The individual lacks the income and resources to pay for the NF services and documentation of what measures have been taken to explore alternatives for payment; and

 

(ii)  A list of the individual’s health insurance(s) plan coverage;

 

3. A signed and dated statement from a licensed physician or licensed nurse practitioner that documents:

 

(i)  He or she is the individual’s primary care provider (PCP);

 

(ii)  The specific services that the individual requires and receives in the NF;

 

(iii)  Services that the individual would need if discharged from the NF;

 

(iv)  The specific needs of the individual that cannot be met in the community if the individual is discharged from the NF;

 

(v)  A brief explanation of the consequences to the individual if deprived of NF services and why the individual’s life or health will be endangered; and

 

(vi)  Appellant’s diagnoses, his or her prognosis, and the severity of his or her condition; and

 

4.  Evidence that the NF has, in good faith, initiated the process to discharge the individual due to a lack of payment; and

 

b.  For HCBC services documents that show the individual lacks the income and resources to pay for the HCBC services, as follows:

 

1.  For applicants a statement dated and signed by the individual’s PCP that documents:

 

i.  The medical services that the individual requires;

 

ii.  A brief explanation of why the imposition of an asset transfer penalty will deprive the individual of medical care such that the individual’s life or health will be endangered; and

 

iii.  A list of the individual’s health insurance(s) plan coverage; or

 

2.  For recipients a statement dated and signed by the individual’s PCP that documents:

 

i.  The medical services that the individual requires;

 

ii. The services that the individual will lose if the asset transfer penalty is imposed, if any;

 

iii.  A brief explanation of why the imposition of an asset transfer penalty will deprive the individual of medical care such that the individual’s life or health will be endangered; and

 

iv.  A list of the individual’s health insurance(s) plan coverage; and

 

(5)  The following verifications shall be required if the request for an asset transfer penalty undue hardship waiver is based upon a claim that the individual will be deprived of food, clothing, shelter, or other necessities of life pursuant to (b)(3)c. above:

 

a.  A signed and dated statement from the individual, or the individual’s agent or representative, explaining how the imposition of a penalty period will result in the deprivation of food, clothing, shelter, or other necessities of life; and

 

b.  Signed and dated statements from the NF or HCBC service providers describing the specific services that the individual needs to avoid being deprived of food, clothing, shelter, or other necessities of life.

 

(d)  Requests for an asset transfer penalty undue hardship waiver, including required verifications, shall be filed no later than 30 calendar days from the date on the notice of asset transfer penalty.

 

(e)  Upon receipt of a request for an asset transfer penalty undue hardship waiver, the department of health and human services (DHHS) shall:

 

(1)  Review the request, attachments, verifications, and any other supporting documentation provided with the request;

 

(2)  Determine whether the request establishes that the individual will suffer an undue hardship if the asset transfer penalty is imposed; and

 

(3)  Notify the individual, or the individual's agent or representative who submitted the request for an asset transfer penalty undue hardship waiver, of DHHS' decision on the request, including the individual's appeal rights.

 

(f)  Failure to comply with the requirements for an asset transfer penalty undue hardship waiver request shall result in the request being denied, unless DHHS determines that there was good cause for the non-compliance.

 

Source.  #9136, eff 4-22-08; ss by #11058, INTERIM, eff 3-24-16, EXPIRED: 9-20-16

 

New.  #12217, eff 6-22-17 (See Revision Note at Part heading for He-W 821)

 

He-W 821.02  Hardship Waiver for Individuals with Substantial Home Equity.

 

(a)  To request a waiver of being denied for or terminated from NF or HCBC services due to excess home equity pursuant to He-W 856.05(d), the individual shall:

 

(1)  Submit a request for a waiver of the eligibility criteria described in He-W 856.05(d), pursuant to (b) below; and

 

(2)  Identify the specific reason(s) for the request from the following list:

 

a.  Being denied for or terminated from NF or HCBC services due to excess home equity would result in the individual being deprived of, and otherwise unable to obtain, necessary care such that his or her individual’s health or life would be endangered; and

 

b.  Being denied for or terminated from NF or HCBC services due to excess home equity would result in the individual being deprived of, and otherwise unable to obtain, food, clothing, shelter, and/or other necessities of life.

 

(b)  The requests for a waiver described in (a) above shall include all of the following:

 

(1)  The individual’s name, address, and telephone number;

 

(2)  Identification of the specific reason(s) for the undue hardship waiver request, pursuant to (a)(2) above;

 

(3)  The name, address, telephone number, and relationship to the individual of the individual’s legal guardian, authorized representative (AR), power-of-attorney, or attorney, if any; and

 

(4)  The printed name and dated signature of the individual or, if filed by the individual’s agent or representative, the printed name and dated signature of the agent or representative, and their relationship to the individual.

 

(c)  A request for a waiver described in (b) shall include all required verification pursuant to (f) and (g) below.

 

(d)  The date the department of health and human services (DHHS) receives the completed request described in (b) and (c) above, shall be the individual’s filing date for a waiver.

 

(e)  The filing date pursuant to (d) above shall be no later than 30 calendar days from the date on DHHS’ notice of a denial or termination of NF or HCBC services.

 

(f)  Individuals shall verify the undue hardship described in (a)(2)a. above by submitting the documentation described in He-W 821.01(c)(1) and:

 

(1)  He-W 821.01(c)(4)a. for NF services; or

 

(2)  He-W 821.01(c)(4)b. for HCBC services.

 

(g)  Individuals shall verify the undue hardship described in (a)(2)b. above by submitting the documentation described in He-W 821.01(c)(1) and:

 

(1)  A signed and dated statement from the individual, or the individual’s agent, or representative, explaining how the imposition of a penalty period due to home equity exceeding the limit will result in the deprivation of food, clothing, shelter, or other necessities of life; and

 

(2)  A signed and dated statement from the NF or HCBC service providers describing the specific services that the individual must retain to avoid being deprived of food, clothing, shelter, or other necessities of life.

 

(h)  Upon receipt of a request for a hardship waiver, DHHS shall:

 

(1)  Review the request, attachments, and any other supporting documentation provided with the request;

 

(2)  Determine whether the request establishes that the individual will suffer an undue hardship if the excess home equity penalty is imposed; and

 

(3)  Notify the individual, or the individual's agent or representative who submitted the request, of DHHS' decision on the request.

 

(i)  Failure to comply with the requirements for the waiver request will result in the request being denied, unless DHHS determines that there was good cause for the non-compliance.

 

Source.  #9136, eff 4-22-08; ss by #11058, INTERIM, eff 3-24-16, EXPIRED: 9-20-16

 

New.  #12217, eff 6-22-17 (See Revision Note at Part heading for He-W 821)

 

He-W 821.03  Administrative Appeals.  Individuals denied waivers described in He-W 821.01 and He-W 821.02 may appeal the department of health and human services’ decision and request an administrative appeal pursuant to He-C 200.

 

Source.  #9136, eff 4-22-08; ss by #11058, INTERIM, eff 3-24-16, EXPIRED: 9-20-16

 

New.  #12217, eff 6-22-17 (See Revision Note at Part heading for He-W 821)

 

PARTS He-W 822 through He-W  823 - RESERVED

 

PART He-W 824  INSTITUTIONAL RESIDENCE

 

He-W 824.01  Institutional Residence.

 

(a)  The following individuals shall not be considered inmates of public institutions or private institutions primarily engaged in treating mental or emotional disorders or tuberculosis:

 

(1)  Individuals who are admitted to the New Hampshire Hospital for purposes of evaluation only, for a period not to exceed 3 months;

 

(2)  Individuals who, while remaining under the general supervision of a public institution as an official inmate of that institution, physically reside outside the institution;

 

(3) Individuals under age 22 or age 65 or older who are certified for care at a designated receiving facility as defined in He-M 405.02(f);

 

(4)  Patients at the psychiatric unit of the Dartmouth - Hitchcock Medical Center;

 

(5)  Children in placement in foster homes or other approved child caring institutions;

 

(6) Children who participate in the special education program at the Sununu Youth Services Center;

 

(7)  Adults in residential care facilities and community living residences; and

 

(8)  Inmates committed by a court order to a NH correctional facility, who require inpatient care at a medical institution as defined in 42 CFR 435.1010.

 

(b)  Individuals who are patients at the Glencliff nursing facility unit of the New Hampshire Hospital shall be considered as residing in a nursing facility.

 

Source.  #11042, eff 2-24-16

 

PARTS He-W 825 through He-W 829

 

PART He-W 830  LIVING WITH A SPECIFIED RELATIVE

 

          He-W 830.01  Living with a Specified Relative.

 

          (a)  For purposes of determining the assistance group for parent caretaker relative medical assistance, "dwelling" means:

 

(1)  An individual's principal residence or place of abode;

 

(2)  The family setting maintained or in the process of being established as a home, as evidenced by assumption, continuation, and exercise of responsibility for day-to-day care and control of the child by the relative with whom the child is living; and

 

(3)  A living unit as defined in (1) and (2) above with no more than one postal address.

 

          (b)  If the dwelling has a separate living unit attached to it with a separate postal address, this living unit shall not be considered part of the same dwelling.

 

          (c)  The department shall consider a child to be living with a specified relative as defined in RSA 167:78,XXIII when the child lives in the same dwelling as defined in (a) above as the specified relative unless the conditions in (e) apply.

          (d)  The department shall consider the specified relative in (c) above to be the casehead for the assistance group.

 

          (e)  If a child lives in the same dwelling as both the child's parent and a non-parent specified relative, the department shall consider the child to be living with the parent.

 

          (f)  The department shall consider the parent in (e) above to be the casehead in the assistance group unless the conditions in (g) below apply.

 

          (g)  If the non-parent specified relative in (e) above is the legal guardian of the child pursuant to RSA 169-C:3,XIV, the department shall:

 

(1)  Consider the non-parent specified relative to be the casehead in the assistance group; and

 

(2)  Consider the parent to be a member of the assistance group pursuant to RSA 167:79,II and He-W 601.01(u).

 

Source.  #13415, eff 7-26-22

 

          He-W 836 – RESERVED

 

PART He-W 837  GRANITE ADVANTAGE HEALTH CARE PROGRAM

 

          He-W 837.01  Definitions.

 

          (a)  “Beneficiary” means an individual determined eligible for the granite advantage health care program.

 

          (b)  “Commissioner” means the commissioner of the NH department of health and human services, or his or her designee.

 

          (c)  “Community engagement requirement” means a condition of continuing eligibility for the granite advantage health care program that requires beneficiaries to engage in 100 hours per calendar month in one or more community engagement activities.

 

          (d)  “Cure” means meeting the community engagement requirement by making up deficit hours, demonstrating good cause for deficit hours, or providing certification of an exemption status.

 

          (e) “Dating violence” means violence committed by a person who is or has been in a social relationship of a romantic or intimate nature with the victim.

 

          (f)  “Deficit hours” means the number of hours below 100 hours that the beneficiary did not participate in community engagement activities in a calendar month.

 

          (g)  “Department” means the New Hampshire department of health and human services.

 

          (h)  “Disability” means disability as defined by the Americans with Disabilities Act (ADA), Section 504 of the Rehabilitation Act, or Section 1557 of the Patient Protection and Affordable Care Act.

 

          (i)  “Disenrollment” means the termination of medicaid eligibility at the annual redetermination of a suspended beneficiary.

 

          (j)  “Domestic violence” means domestic violence as defined in RSA 631:2-b.

 

          (k)  “Granite advantage health care program (granite advantage)” means the granite advantage health care program established under RSA 126-AA which provides medicaid coverage to adults eligible under Title XIX of the Social Security Act 1902(a)(10)(A)(i)(VIII).

 

          (l)  “Good cause” means circumstances that prevented the beneficiary from meeting the community engagement requirement pursuant to He-W 837.10.

 

          (m) “Homeless” means a situation in which an individual lacks a fixed, regular, and adequate nighttime residence such as living in a publicly or privately operated shelter, or living in a public or private location not meant for human habitation, and includes a situation in which an individual is in peril of losing his or her primary residence, no subsequent residence has been identified, and the individual lacks support networks to obtain permanent housing.

 

          (n)  “Immediate family member” means a spouse, child(ren), mother-in-law, father-in-law, parent(s), step-parent(s), step-child(ren), step-brother(s), step-sister(s), grandparent(s), grandchild(ren), brother(s), sister(s), legal guardian(s), daughter(s)-in-law, son(s)-in-law, brother(s)-in-law, sister(s)-in-law, and foster child(ren).

 

          (o) “Licensed medical professional” means a physician, an advanced practice registered nurse (APRN), a behavioral health professional who is able to determine eligibility for community mental health services pursuant to He-M 401.04, a physician assistant, a licensed alcohol and drug counselor (LADC), a master of licensed alcohol and drug counselor (MLADC), nurse case manager, or a board-certified psychologist.

 

          (p)  “Medicaid” means the Title XIX program administered by the department, which makes medical assistance available to eligible individuals.

 

          (q)  “Medically frail” means a beneficiary, as defined in 42 CFR 440.315(f), with a disabling mental disorder, chronic substance use disorder (SUD), serious and complex medical condition, or a physical, intellectual, or developmental disability that significantly impairs the ability to perform one or more activities of daily living as certified by a licensed medical professional.

 

          (r)  “Noncompliant” means a status where a beneficiary failed to meet the 100 hour per calendar month community engagement requirement in a single month.

 

          (s)  “Redetermination” means the annual medicaid eligibility renewal process required by 42 CFR 435.916, He-W 606, and He-W 684.

 

          (t)  “Stalking” means engaging in a course of conduct directed at a specific person that would cause a reasonable person to fear for the person’s individual safety or the safety of others or suffer substantial emotional distress.

 

          (u)  “Sexual assault” means sexual assault as defined in RSA 632-A:4.

 

          (v)  “Voluntary” means a community engagement status in which a beneficiary is not required to participate in the community engagement requirement but chooses to do so.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19

 

          He-W 837.02  Community Engagement Requirement.

 

          (a)  Unless exempted under He-W 837.03 below or able to demonstrate good cause under He-W 837.10, beneficiaries shall engage in 100 hours per calendar month in one or more of the community engagement activities listed in He-W 837.05 below.

 

          (b)  A beneficiary shall have until the first full month following 75 calendar days from the date of the eligibility determination or the expiration of an exemption to come into compliance with the community engagement requirement.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.03)

 

          He-W 837.03  Exemptions.

 

          (a)  Beneficiaries meeting at least one of the following conditions shall be exempted from the community engagement requirement:

 

(1)  Beneficiaries who are unable to participate due to illness, incapacity, or treatment, as certified by a licensed medical professional.  This exemption shall include the beneficiary’s participation in inpatient and residential outpatient SUD treatment or intensive outpatient SUD services that is consistent with Levels 2.1 and above as found in the American Society of Addiction Medicine (ASAM) Criteria:  Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, Third Edition (2013), henceforth referred to as “ASAM Criteria 2013”, available as noted in Appendix A;

 

(2)  Beneficiaries who are participating in a state-certified drug court program;

 

(3)  A custodial parent or caretaker as defined in RSA 167:82, II(g) where the required care is considered necessary by a licensed medical professional;

 

(4)  A custodial parent or caretaker of a dependent child under 6 years of age provided that the exemption shall only apply to one parent or caretaker of a common child or children in the case of a 2-parent household;

 

(5)  A custodial parent or caretaker of a child with developmental disabilities who is residing with the parent or caretaker;

 

(6)  Pregnant women as defined in 42 CFR 435.4;

 

(7)  Beneficiaries with a disability who are unable to comply with the community engagement requirement due to disability-related reasons;

 

(8)  Beneficiaries residing with an immediate family member who has a disability and is unable to meet the community engagement requirement for reasons related to the family member’s disability;

 

(9)  Beneficiaries who experience a hospitalization or serious illness;

 

(10)  Beneficiaries residing with an immediate family member who experiences a hospitalization or serious illness; or

 

(11)  Beneficiaries who are medically frail, as certified by a licensed medical professional.

 

          (b)  Beneficiaries meeting at least one of the conditions in (a)(1) – (11) above shall complete the required form for the condition as specified for the condition in accordance with He-W 837.04 below.

 

          (c)  Beneficiaries who fall in at least one of the following categories, based on the information available in the department’s eligibility system(s), shall be exempted from the community engagement requirement and shall not have to supply additional information to the department:

 

(1)  Beneficiaries who are approved by the department for aid to the permanently and totally disabled (APTD), aid to the needy blind (ANB), medicaid for employed adults with disabilities (MEAD), nursing facility, home and community based services (HCBS), or home care for children with severe disabilities through age 20 (HC-CSD);

 

(2)  Beneficiaries who are receiving supplemental security income (SSI), social security disability income (SSDI), railroad disability, or veteran disability benefits;

 

(3)  Beneficiaries who are pregnant as defined in 42 CFR 435.4, and whose pregnancy status is indicated in the department’s eligibility system(s);

 

(4)  A beneficiary who is a custodial parent or caretaker for a dependent child under 6 provided that the exemption shall only apply to one parent or caretaker of a common child or children in the case of a 2-parent household;

 

(5)  A beneficiary who is a custodial parent or caretaker of a child with developmental disabilities who is residing with the parent or caretaker and who is currently approved by the department for services under the home and community based services developmental disability waiver (HCBS-DD);

 

(6)  Beneficiaries who are receiving supplemental nutritional assistance program (SNAP) benefits and who are exempt from the program’s employment requirements;

 

(7)  Beneficiaries who are receiving temporary assistance for needy families (TANF) benefits and who are exempt from the program’s employment requirements; and

 

(8)  Beneficiaries who are enrolled in health insurance premium program (HIPP).

 

          (d)  The exemptions in (c) above shall continue for as long as the particular circumstance continues to exist.

 

          (e)  A beneficiary who is exempted in (c) above may request to participate voluntarily in the community engagement requirement and shall have access to the granite workforce program pursuant to He-W 639.

 

          (f)  Beneficiaries voluntarily participating in the community engagement requirement in (e) above shall not be subject to suspension or termination for noncompliance with the community engagement requirement.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.04)

 

          He-W 837.04  Request for Exemption; Duration of Exemptions.

 

          (a)  All beneficiaries requesting an exemption shall complete and submit BFA Form 330 “Exemption Request Form Granite Advantage Health Care Program” (06/19).

 

          (b)  Beneficiaries requiring certification by a licensed medical professional in (c) below shall have a licensed medical professional certify on BFA Form 330  to the following:

 

“As a licensed medical professional caring for this beneficiary, I hereby certify (based on the description of the exemptions provided in the instructions to this form) that the beneficiary meets the qualifications for the exemption(s) requested in Section II.”

 

          (c)  Beneficiaries shall provide the following third party certification or documentation to the department for the indicated exemption types:

 

(1)  For beneficiaries unable to participate due to illness, incapacity, or treatment under He-W 837.03(a)(1) above, provide a certification by a licensed medical professional specifying the duration and limitations of the illness, incapacity, or treatment.  The duration of the exemption shall be one month or the date range specified by the licensed medical professional, whichever is longer;

 

(2)  For beneficiaries participating in a state certified drug court program under He-W 837.03(a)(2) above, provide a copy of the legal documentation requiring the beneficiary to participate in the drug court program.  The duration of this exemption shall be one year from the date that the required documentation is received;

 

(3)  For a parent or caretaker under He-W 837.03(a)(3) above, provide a certification by a licensed medical professional that specifies the duration that such care is required.  Unless specified otherwise by the licensed medical professional, the duration of this exemption shall be one year from the date that the required documentation is received;

 

(4)  For a parent or caretaker of a dependent child under 6 years of age under He-W 837.03(a)(4) above, provide a self-attestation and the child’s date of birth;

 

(5)  For a custodial parent or caretaker of a child with developmental disabilities under He-W 837.03(a)(5) above, provide a certification by a licensed medical professional of the child’s developmental disability.  The duration of this exemption shall be for as long as the particular circumstance continues to exist;

 

(6)  For beneficiaries with a disability under He-W 837.03(a)(7) above, provide an annual certification by a licensed medical professional of the beneficiary’s inability to meet the community engagement requirement for reasons related to the disability.  The duration of this exemption shall be one year from the date that the required documentation is received or the date range specified by the licensed medical professional, whichever is less;

 

(7)  For beneficiaries residing with an immediate family member with a disability under He-W 837.03(a)(8) above, provide an annual attestation of the beneficiary’s inability to meet the community engagement requirement for reasons related to the family member’s disability and an annual certification by the family member’s licensed medical professional specifying the family member’s disability.  The duration of this exemption shall be one year from the date that the required documentation is received or the date range specified by the licensed medical professional, whichever is less;

 

(8)  For beneficiaries unable to participate due to hospitalization or serious illness under He-W 837.03(a)(9) above, provide copies of discharge summaries, or financial or billing information, documenting the hospitalization or serious illness or dates of stay.  The duration of this exemption shall be one month or the date range specified by the licensed medical professional, whichever is longer;

 

(9)  For beneficiaries who are unable to participate due to hospitalization or serious illness of an immediate family member under He-W 837.03(a)(10) above, provide copies of the family member’s discharge summaries, or financial or billing information, documenting the hospitalization or serious illness.  The duration of this exemption shall be one month or the date range specified by the licensed medical professional, whichever is longer; and 

 

(10)  For medically frail beneficiaries under He-W 837.03(a)(11) above, an annual completion and submission of a.  and b.  below:

 

a.  BFA Form 320A “Beneficiary Authorization for Licensed Medical Professional to Release Protected Health Information - Granite Advantage Health Care Program” (05/19) permitting and authorizing disclosure of protection health information as follows:

 

“I hereby authorize the following licensed medical professional to disclose my protected health information for the purposes described above.”

 

“In addition, I hereby authorize the following specific disclosures (place your initials on the line by those statements which apply)

I specifically authorize the release of my mental health treatment records.

I specifically authorize the release of my HIV and AIDS results and/or treatment.

I specifically authorize the release of my alcohol and/or drug abuse treatment records in accordance with 42 CFR Part 2.”

 

“I give authorization for my protected health information to be released to the following individual or organization:

 

Name:  Granite Advantage Health Care Program Manager

Organization:  Department of Health and Human Services

Address:  DHHS, Granite Advantage Health Care Program, P.O. Box 3778, Concord, NH 03302-3778 or Fax # 603-271-5623

 

I understand this authorization may be revoked by notifying the Department of Health and Human Services in writing to the address above”; and

 

b.  BFA Form 331 “Licensed Medical Professional Certification of Medical Frailty Granite Advantage Health Care Program” (05/19) indicating that the beneficiary is unable to comply with the work and community engagement requirement as a result of their condition including the duration of such disability.  The duration of this exemption shall be one year from the date that the required certification is received or the date range specified by the licensed medical professional, whichever is less.  The licensed medical professional shall certify as follows:

 

“As a licensed medical professional caring for this beneficiary, I hereby certify that the beneficiary is medically frail based on the beneficiary having one or more of the conditions identified above.”

 

          (d)  To the extent practicable, third party certification or documentation shall be submitted to the department with the form required in (a) above.

 

(e)  A request for an exemption under this section shall not be considered complete until all of the required documentation is received by the department.

 

(f)  For pregnant women, the beneficiary may report pregnancy by completing and submitting BFA Form 330 or by informing the department.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.05); BFA form 330 in (a) amd by #12828

 

He-W 837.05  Qualifying Activities.  The following activities shall qualify as activities for the community engagement requirement:

 

(a)  Unsubsidized employment including by non-profit organizations;

 

(b)  Subsidized private sector employment;

 

(c)  Subsidized public sector employment;

 

(d)  On-the-job training;

 

(e)  Job skills training related to employment;

 

(f)  Enrollment at an accredited community college, college, or university that is counted on a credit hour basis;

 

(g)  Job search and job readiness assistance, including but not limited, to participation in job search or job training activities offered through the department of employment security or through other job search or job readiness assistance programs such as the Workforce Innovation and Opportunity Act (WIOA) or work ready New Hampshire.  Time spent in any assessment, training, enrollment, or case management activity that is necessary for participation in a job search or job readiness program shall be credited as job search and job readiness assistance hours;

 

(h)  Vocational educational training not to exceed 12 months with respect to any beneficiary;

 

(i)  Education directly related to employment, in the case of a beneficiary who has not received a high school diploma or certificate of high school equivalency;

 

(j)  Attendance at secondary school or in a course of study leading to a certificate of general equivalence, in the case of a beneficiary who has not completed secondary school or received such a certificate;

 

(k)  Community, volunteer, or public service except that community, volunteer, or public service under this part shall not include services provided to or on behalf of a political organization or campaign;

 

(l)  Caregiving services for a non-dependent relative or other person with a disabling medical, mental health, or developmental condition;

 

(m)  Participation in ASAM Level 1 outpatient SUD services, including medication assisted treatment, and recovery supports, as set forth in ASAM Criteria (2013);

 

(n)  Participation in and compliance with SNAP employment requirements;

 

(o)  Participation in and compliance with the TANF employment requirements;

 

(p)  Participation in and compliance with the employment requirements of the refugee resettlement program pursuant to 45 CFR 400.75; or

 

(q)  Self-employment.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.06)

 

He-W 837.06  Reporting of Community Engagement Activities and Crediting of Hours.

 

(a)  The following types of community engagement activities shall be reported by completing and submitting BFA Form 321 “Reporting Education Participation for Community Engagement – Granite Advantage Health Care Program” (06/19):

 

(1)  For job skills training related to employment under He-W 837.05(e), the beneficiary shall provide documentation of enrollment that includes the duration and the number of hours per month the beneficiary is participating in the activity;

 

(2)  For enrollment at an accredited community college under He-W 837.05(f), the beneficiary shall provide documentation of enrollment that includes a copy of the beneficiary’s class schedule, the number of credit hours assigned for the enrolled class(es), and the semester begin and end date.  The number of community engagement hours to be credited shall be determined by multiplying the number of credit hours assigned for the enrolled class(es) by 4.33;

 

(3)  For vocational educational training under He-W 837.05(h), the beneficiary shall provide documentation of enrollment that includes the duration of the activity and a copy of the beneficiary’s enrollment in the program.  Community engagement hours shall be credited at 100 hours per month for the duration of the beneficiary’s verified participation in the activity not to exceed 12 months;

 

(4)  For education directly related to employment under He-W 837.05(i), the beneficiary shall provide documentation of enrollment that includes the duration of the activity.  Community engagement hours shall be credited at 100 hours per month for the duration of the beneficiary’s verified participation in the activity; and

 

(5)  For study leading to a certificate of general equivalence under He-W 837.05(j), the beneficiary shall provide documentation of enrollment that includes the duration of the activity.  Community engagement hours shall be credited at 100 hours per month for the duration of the beneficiary’s verified participation in the activity;

 

(b)  The types of community engagement activities listed in (c) below shall be reported on a completed and submitted BFA Form 320 “Reporting Monthly Participation in Community Engagement Activities -  Granite Advantage Health Care Program” (06/19).

 

(c)  Beneficiaries shall provide the requested information on the form in (b) above, and the hours reported on the form in (b) above shall be credited toward the community engagement requirement as follows:

 

(1)  For time spent participating in job search and job readiness efforts under He-W 837.05(g), the beneficiary shall report the type, duration of the activity, and total number of hours per month;

 

(2)  For community, volunteer, or public service under He-W 837.05(k), the beneficiary shall report where and when the community, volunteer, or public service was performed, the number of hours performed, and the contact information for the organization or individual the service was performed for;

 

(3)  For caregiving services under He-W 837.05(l), the beneficiary shall report the name and contact information for the non-dependent relative or other person cared for, a description of the services provided, and the number of hours of caregiving services provided;

 

(4)  For participation in ASAM Level 1, as set forth in ASAM Criteria (2013), outpatient SUD services under He-W 837.05(m), the beneficiary shall report the name of the agency or organization the services were received from, and the number of hours that the beneficiary participated in the services up to 40 hours per month.  For participation in any other ASAM level treatment, see exemption He-W 837.03(a)(1);

 

(5)  For beneficiaries experiencing a temporary increase in monthly employment hours for seasonal work or for other such work greater than the beneficiary’s average monthly employment hours as credited pursuant to (d)(4) below, the beneficiary shall report the increased hours which shall be limited to 2 consecutive months; and

 

(6)  For beneficiaries who are self-employed and work more hours than calculated by the department’s eligibility system(s), the beneficiary shall report the additional hours worked, and a description of the hours work and tasks performed.

 

(d)  The indicated community engagement activities below shall be credited as follows if the activity is verified by the department’s eligibility system(s):

 

(1)  For system-verified participation in and compliance with SNAP employment requirements, community engagement hours shall be credited at 100 hours per month for the duration of the beneficiary’s verified participation in the program;

 

(2)  For system-verified participation in and compliance with TANF employment requirements, community engagement hours shall be credited at 100 hours per month for the duration of the beneficiary’s verified participation in the program;

 

(3)  For participation in and compliance with the employment requirements of the refugee resettlement program pursuant to 45 CFR 400.75, systemic verification of legal status and enrollment in the program.  and community engagement hours shall be credited at 100 hours per month for 12 months from the date of the beneficiary’s entry into the United States; and

 

(4)  Employment information gathered during the application or redetermination process or in the department’s eligibility system(s) shall be used to determine a beneficiary’s average monthly employment hours and shall be credited towards the community engagement requirement for employment activities listed in He-W 837.05(a)-(d).

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.07); BFA form 321 in (a) and BFA form 320 in (b) amd by #12828

 

He-W 837.07  Beneficiaries with Disabilities:  Reasonable Modification.

 

(a)  A beneficiary with a disability shall be entitled to reasonable modifications related to meeting the community engagement requirement.

 

(b)  Reasonable modifications shall include:

 

(1)  Modification in the number of community engagement hours required where the beneficiary is unable to participate in the required number of hours; or

 

(2)  Assistance with understanding granite advantage to include, but not be limited to, departmental notices, eligibility requirements, exemption requirements, how to apply for an exemption, program benefits, how to establish eligibility, and how to meet and report community engagement activities to maintain eligibility.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.08)

 

He-W 837.08  Opportunity to Cure.

 

(a)  If a beneficiary fails to meet the required community engagement hours, the beneficiary shall satisfy the community engagement requirement by making up the deficit hours for the noncompliant month by doing one of the following:

 

(1)  Curing the deficit hours by engaging in the activities listed in He-W 837.05 above in the following month for only the number of deficit hours for the noncompliant month.  For example:

 

a.  A beneficiary engaged in 60 hours of community engagement activities in January, resulting in a 40-hour deficit.  The beneficiary worked 100 hours in February.  The beneficiary’s noncompliance for January shall be cured, and the beneficiary shall be considered compliant with February; or

 

b.  A beneficiary engaged in 60 hours of community engagement activities in January, resulting in a 40-hour deficit.  The beneficiary shall only need to complete 40 hours of community engagement activities in February to cure January’s deficit.  The beneficiary worked 60 hours in February.  The beneficiary shall be considered compliant for January, and shall be considered noncompliant for February with a 40-hour deficit;

 

(2)  Demonstrating good cause for the failure to meet the community engagement requirement as described in He-W 837.10; or

 

(3)  Providing documentation of an exemption pursuant to He-W 837.04.

 

(b)  Within 10 days following the noncompliant month, the department shall provide written notice to the beneficiary of failure to meet the community engagement requirement to include:

 

(1)  How a beneficiary can cure the noncompliance as described in (a) above; and

 

(2)  Information regarding potential suspension pursuant to He-W 837.9 below.

 

(c)  At no time shall a beneficiary be required to work more than 100 hours in a single month.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.09)

 

          He-W 837.09  Suspension.

 

(a)  If a beneficiary does not cure the deficit hours as described in He-W 837.08(a), the department shall suspend the beneficiary’s eligibility effective the first of the month following the one-month opportunity to cure, subject to appeal pursuant to He-W 837.17.

 

(b)  Prior to suspension, the department shall provide, at a minimum, a ten-day written notice to the beneficiary that his or her medicaid eligibility shall be suspended due to noncompliance, and shall include all applicable notice requirements found in 42 CFR 431, Subpart E, and appeal rights pursuant to He-W 837.17.

 

(c) The suspension shall remain in effect until the beneficiary reactivates eligibility prior to redetermination by:

 

(1)  Satisfying within a single calendar month the deficit hours from the noncompliant month or by satisfying within a single calendar month the deficit hours from the cure month, whichever is less;

 

(2)  Demonstrating within a single calendar month enough good cause hours pursuant to He-W 837.10 and He-W 837.11 to fully cover the number of deficit hours;

 

(3)  Demonstrating within a single calendar month a combination of community engagement hours and good cause hours sufficient to fully cover the number of deficit hours;

 

(4)  Providing documentation of an exemption pursuant to He-W 837.04; or

 

(5)  Becoming eligible for medicaid under an eligibility category that is not subject to the community engagement requirement.

 

(d)  Reactivation shall be effective:

 

(1)  On the date that the deficit hours are reported to the department;

 

(2)  On the date the department receives the required attestation or third party certification or documentation to establish good cause or an exemption; or

 

(3)  On the date that the beneficiary was admitted to the hospital where the beneficiary was found to have good cause pursuant to He-W 837.10(a)(8) or an exemption under He-W 837.03, and has good cause or an exemption within 30 calendar days of the date of their hospital discharge.

 

(e)  Upon reactivation in (d) above, a beneficiary’s obligation to meet the community engagement requirement shall begin on the first full month following the month in which the beneficiary’s eligibility is reactivated.

 

(f)  After suspension, a beneficiary shall not be required to complete a new medicaid application if she or he has met one of the requirements of (c) above.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.10)

 

He-W 837.10  Good Cause.

 

(a)  Good cause shall include, but not be limited to, the following circumstances:

 

(1)  The beneficiary experiences the birth or death of a family member residing with the beneficiary;

 

(2)  The beneficiary experiences severe inclement weather, including a natural disaster, and was unable to meet the requirement;

 

(3)  The beneficiary has a family emergency or other life-changing event such as divorce;

 

(4)  The beneficiary is a victim of domestic violence, dating violence, sexual assault or stalking;

 

(5)  The beneficiary is a custodial parent or caretaker of a child 6 to 12 years of age who, as determined by the commissioner on a monthly basis, is unable to secure child care in order to participate in community engagement activities either due to a lack of child care scholarship or the inability to obtain a child care provider due to capacity, distance, or another related factor;

 

(6) The beneficiary has a disability, and was unable to meet the community engagement requirement for reasons related to that disability;

 

(7)  The beneficiary resides with an immediate family member who has a disability, and was unable to meet the community engagement requirement for reasons related to the family member’s disability, but did not request an exemption from the community engagement requirement;

 

(8)  The beneficiary experienced a hospitalization, but did not request an exemption from the community engagement requirement;

 

(9)  The beneficiary resides with an immediate family member who experienced a hospitalization or serious illness, but the beneficiary did not request an exemption from the community engagement requirement;

 

(10)  The beneficiary is homeless; or

 

(11)  Other good cause exists, such as circumstances beyond the beneficiary’s control which related to the beneficiary’s ability to obtain or retain a qualifying community engagement activity.  Other good cause shall include an illness that did not require inpatient hospitalization.

 

(b)  All beneficiaries requesting a finding of good cause shall complete and submit BFA Form 340 “Good Cause Request Form - Granite Advantage Health Care Program” (04/19) along with any required third party certification(s) to the department.

 

(c)  Beneficiaries requiring certification by licensed medical professional for good cause in (d) below shall have the licensed medical professional certify on BFA Form 340 “Good Cause Request Form.  Granite Advantage Health Care Program” (06/19) as follows:

 

“A showing of good cause for “disability” or “Caretaker residing with immediate family member with disability” requires certification by a licensed medical professional.  As a licensed medical professional caring for this beneficiary or for a beneficiary’s family member with a disability, I hereby certify that:  The beneficiary is disabled and unable to meet the community engagement requirement for reasons related to their disability; or the family member identified above is disabled.”

 

(d)  A beneficiary’s request for a finding of good cause shall be attested to and certified as follows:

 

(1)  For a beneficiary who experiences the birth or death of a family member residing with the beneficiary, attestation by the beneficiary of the event to include the name of the family member, the date of the event, the family member’s relationship to the beneficiary, and the number of days impacted;

 

(2)  For a beneficiary who experiences severe inclement weather, including a natural disaster, and therefore was unable to meet the requirement, attestation by the beneficiary of the date(s) of the severe inclement weather or natural disaster, and the number of days impacted;

 

(3)  For a beneficiary who has a family emergency or other life-changing event such as divorce, attestation by the beneficiary of the nature of the family emergency or life-changing event to include the date(s) and the number of days that the beneficiary was unable to participate due to the circumstance;

 

(4)  For a beneficiary who is a victim of domestic violence, dating violence, sexual assault, or stalking, documentation of the date range specified in the court order or self-attestation to the number of days impacted;

 

(5)  For custodial parents as described in (a)(5) above, a monthly attestation by the beneficiary of the inability to secure child care and the number of days impacted;

 

(6)  For a beneficiary who has a disability, , and was unable to meet the requirement for reasons related to that disability the following shall be required:

 

a.  Attestation by the beneficiary of the number of days the beneficiary was unable to meet the community engagement requirement for reasons related to the disability; and

 

b.  The certification described in (c) above;

 

(7)  For a beneficiary who resides with an immediate family member who has a disability, and was unable to meet the requirement for reasons related to the family member’s disability, but did not request an exemption from the community engagement requirement, the following shall be required:

 

a.  Attestation by the beneficiary of the number of days the beneficiary was unable to meet the community engagement requirement for reasons related to that disability; and

 

b.  The certification described in (c) above;

 

(8)  For a beneficiary who experienced a hospitalization, but did not request an exemption from community engagement requirement, the following shall be required:

 

a.  Attestation by the beneficiary of the number of days of the hospitalization and the admission date; and

 

b.  Copies of the discharge summaries, or financial or billing information that would substantiate the hospitalization or certification by a licensed medical professional;

 

(9)  For a beneficiary who resides with an immediate family member who experienced a hospitalization or serious illness, but the beneficiary did not request an exemption from community engagement requirement, the following shall be required:

 

a.  Attestation by the beneficiary of the number of days of the hospitalization or serious illness or certification by a licensed medical professional; and

 

b.  Copies of the family member’s discharge summary, or financial or billing information, or other medical records that would substantiate the hospitalization or serious illness;

 

(10)  For a beneficiary who is homeless, attestation by the beneficiary of the beneficiary’s homelessness or inability to find stable housing and the number of days the beneficiary was unable to meet the community engagement requirement; or

 

(11)  For a beneficiary to claim other good cause under (a)(11), attestation by the beneficiary of the circumstance beyond the beneficiary’s control which relate to the beneficiary’s ability to obtain or retain a community engagement activity to participate in, and the number of days the beneficiary was unable to meet the community engagement requirement.

 

(e)  A request for a finding of good cause under this section shall not be approved unless the required attestation(s) and certification(s) are received by the department.

 

(f)  The department shall use the documentation received to determine if the community engagement requirement would have been met if not for the good cause.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.11); BFA form 340 in (c) amd by #12828

 

He-W 837.11  Crediting a Finding of Good Cause.

 

(a)  A finding of good cause shall be credited toward the monthly community engagement requirement as follows:

 

(1)  For a beneficiary who experiences the birth or death of a family member residing with the beneficiary, 8 hours per day for each day the beneficiary attested being unable to participate;

 

(2)  For a beneficiary who experiences severe inclement weather including a natural disaster, 8 hours per day for each day the beneficiary attested being unable to participate;

 

(3)  For a beneficiary who has a family emergency or other life changing event such as divorce, 8 hours per day for each day the beneficiary attested being unable to participate;

 

(4)  For a beneficiary who is a victim of domestic violence, dating violence, sexual assault, or stalking, 8 hours per day for each day the beneficiary attested being unable to participate or the date range specified in the court order;

 

(5)  For a beneficiary who is a custodial parent or caretaker of a child 6 to 12 years of age who is unable to secure child care in order to participate in community engagement, 8 hours per day for each day the beneficiary attested being unable to participate;

 

(6)  For a beneficiary with a disability who was unable to meet the requirement for reasons related to that disability, 8 hours per day for each day the beneficiary was unable to participate, or, if no date range is indicated, 100 hours per month for each month the beneficiary was unable to participate;

 

(7)  For a beneficiary residing with an immediate family member who has a disability, and was unable to meet the requirement for reasons related to the family member’s disability, 8 hours a day for each day the beneficiary was unable to participate, or, if no date range is indicated, 100 hours per month for each month the beneficiary was unable to participate;

 

(8)  For a beneficiary who experiences a hospitalization, but did not request an exemption the following shall apply:

 

a.  For inpatient hospitalization, 100 hours per month for each month the beneficiary was unable to participate; or

 

b.  For outpatient hospitalization, 8 hours per day for each day the beneficiary was unable to participate as documented through self-attestation or a certification by a licensed medical professional;

 

(9)  For a beneficiary who resides with an immediate family member who experienced a hospitalization or serious illness, but the beneficiary did not request an exemption the following shall apply:

 

a.  For inpatient hospitalization, 8 hours per day for each day the beneficiary attested being unable to participate; or

 

b.  For outpatient hospitalization or serious illness, 8 hours per day for each day the beneficiary was unable to participate as documented through self-attestation or a certification by a licensed medical professional;

 

(10)  For a beneficiary who is homeless or unable to find stable housing, 8 hours per day for each day the beneficiary attested being unable to participate; and

 

(11)  For other good cause, 8 hours per day for each day the beneficiary attested being unable to participate.

 

(b)  If the beneficiary’s good cause did not fully cover the number of deficit hours in that month, the beneficiary shall be determined noncompliant for the month, resulting in the beneficiary’s responsibility to cure as required in He-W 837.08(a).

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.12)

 

He-W 837.12  Limitation on the Repeated Consecutive Use of Curing to Meet the Community Engagement Requirement.

 

(a)  Beginning May 1, 2020, a beneficiary, who engages in the repeated consecutive use of cure for 12 months immediately prior to redetermination, shall be suspended at redetermination.

 

(b)  Following suspension in (a) above, a beneficiary may reactivate eligibility under this section by providing 100 hours of community engagement within a single calendar month.

 

(c)  Reactivation shall be effective on the date the 100 community engagement hours are reported to the department.

 

(d)  After reactivation in (c) above, a beneficiary’s participation start date shall be the 1st of the month following the month in which the beneficiary’s eligibility is reactivated.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.13)

 

He-W 837.13  Extra Hours.  A beneficiary shall not be permitted to carry-over hours in excess of the 100-hour requirement in order to satisfy the community engagement requirement.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.14)

 

He-W 837.14  Disenrollment and Reconsideration.

 

(a)  A beneficiary who is suspended for noncompliance with the community engagement requirement, and fails to cure that suspension during redetermination, shall be disenrolled from granite advantage.

 

(b)  A disenrolled beneficiary shall be re-enrolled as follows:

 

(1)  Within 90 days of disenrollment, a beneficiary may return to granite advantage by providing 100 hours of community engagement within a single calendar month;

 

(2)  Upon the department’s receipt of the reported 100 hours in (b)(1) above, the beneficiary’s eligibility shall be reopened as of the date that the hours are reported to the department; and

 

(3)  The beneficiary’s participation start date shall be the 1st of the month following the report in (b)(2) above.

 

(c)  A beneficiary who is compliant with the community engagement requirement at redetermination but whose eligibility is terminated at redetermination for other reasons may, within 90 days of disenrollment, return to granite advantage by:

 

(1)  Satisfying any outstanding medicaid redetermination requirements pursuant to 42 CFR 435.119, 42 CFR 435.916, He-W 606, and He-W 684;

 

(2) Upon satisfying any outstanding redetermination requirements in (c)(1) above, the beneficiary’s eligibility shall be reactivated to the date of closure; and

 

(3)  The beneficiary shall resume the reporting of community engagement hours the 1st of the month following the month that the outstanding redetermination requirements are met.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.15)

 

He-W 837.15  Re-Application.

 

(a)  A beneficiary may reapply for medicaid at any time after disenrollment.

 

(b)  If a beneficiary reapplies, the following shall apply:

 

(1)  A beneficiary who was disenrolled at redetermination and who reapplies within 6 months and is determined eligible, shall begin to report community engagement hours on the 1st of the month following the month in which the application is filed;

 

(2)  A beneficiary, who was disenrolled at redetermination and who reapplies 6 or more months thereafter and is determined eligible, shall in accordance with He-W 837.02 have until the first full month following 75 calendar days from the date of their eligibility determination before he or she is required to meet the 100-hour community engagement requirement; and

 

(3)  For purposes of this section, the 6-month period shall be calculated using 365/2 rounded down equaling 182 days.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.16)

 

He-W 837.16  Screening for Other Bases of Medicaid Eligibility Prior to Suspension, Termination, Disenrollment, or Denial of Eligibility.  Suspension, termination, disenrollment, or denial of eligibility shall only occur after a beneficiary is screened and determined to be ineligible for all other bases of medicaid eligibility and reviewed for eligibility for insurance affordability programs in accordance with 42 CFR 435.916(f).

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.17)

 

He-W 837.17  Appeals.

 

(a)  A beneficiary may appeal the department’s decision denying an exemption under He-W 837.04, denying a request for good cause under He-W 837.10, denying a reasonable modification under He-W 837.07, or suspending, denying, or terminating the beneficiary’s eligibility for failing to meet the community engagement requirement under He-W 837.02 by filing a request for an appeal with the department’s administrative appeals unit in accordance with He-C 200.

 

(b)  The department shall not suspend, deny, or terminate the beneficiary’s eligibility under (a) above if the beneficiary:

 

(1)  Submits a hearing request to the local district office within 30 days from the date on the written notice of adverse decision; and

 

(2)  Submits a request to the local district office for a continuation of benefits during the appeal process within 15 days of the date on the written notice of adverse decision.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.18)

 

He-W 837.18  Other Department Obligations.

 

(a)  The department shall periodically assess compliance with the community engagement requirement in labor market areas, within the state, to assess whether mitigation strategies are needed so that the community engagement requirement is not unreasonably burdensome.

 

(b)  The department shall examine the following:

 

(1)  Areas that experience high rates of unemployment;

 

(2)  Areas with limited economies and educational opportunities; and

 

(3)  Areas with a lack of public transportation.

 

(c)  The department shall provide information and assistance to beneficiaries, including oral and written explanations, regarding community engagement activities, exemptions from participation in the community engagement requirement, good cause exemptions, appeal rights, suspension, disenrollment, and termination, and the opportunity to cure to facilitate beneficiaries’ compliance with the program’s community engagement requirement, and any other information related to the community engagement requirement and this part.

 

(d)  The department shall develop an eligibility and enrollment monitoring plan that includes metrics, timetables, and programmatic content to ensure processes are in place.

 

(e)  The plan shall include the collection and analysis of data for the following data points:

 

(1)  The number and percentage of beneficiaries who have requested exemption from the community engagement requirement;

 

(2)  The number and percentage of beneficiaries who have been granted an exemption from the community engagement requirement;

 

(3)  The number and percentage of community engagement good cause requested;

 

(4)  The number and percentage of beneficiaries granted good cause from the community engagement requirement;

 

(5)  The number and percentage of beneficiaries whose eligibility was terminated at redetermination for not meeting the community engagement requirement;

 

(6)  The number and percentage of community engagement appeal requests; and

 

(7)  The number and percentage of beneficiaries whose eligibility was suspended for failing to comply with the community engagement requirement.

 

Source.  #12733, INTERIM, eff 2-23-19, EXPIRES: 8-22-19; ss by #12796, eff 6-5-19 (formerly He-W 837.19)

 

PART He-W 841 

 

He-W 841.03  Medicaid for Employed Adults with Disabilities (MEAD).

 

(a) In accordance with RSA 167:3-i, RSA 167:3-c, XII, RSA 167:6, IX, and 42 USC 1396a(a)(10)(A)(ii)(XV) relative to medical assistance for employed adults with disabilities, medical assistance shall be provided to any applicant who:

 

(1)  Meets the general and technical requirements for aid to the permanently and totally disabled (APTD) or aid to the needy blind (ANB) as specified in He-W 600 and He-W 800;

 

(2)  Is age 18 through 64, inclusive;

 

(3)  Meets the medical criteria for MEAD pursuant to He-W 504.02;

 

(4)  Is employed for pay pursuant to He-W 841.03(b), or self-employed for pay pursuant to He-W 841.03(c), on the date of application, during the time of MEAD eligibility determination, and during the retroactive period, should the individual request this medical coverage period;

 

(5)  Has net income determined by applying the APTD or ANB treatment and disregards to his or her gross income, and if applicable, to the spouse’s gross income pursuant to He-W 654 and He-W 854, that when combined with spousal net income does not exceed 450% of the federal poverty guidelines, as published annually in the federal register and effective no later than the first of the month following the first complete month after the federal poverty income guidelines have been published in the federal register;

 

(6)  Has countable resources that do not exceed the 2002 limit of $20,000 for an individual or $30,000 for a married couple, the amounts of which shall be updated annually in accordance with (a)(5) above by the percentage that applies pursuant to the Consumer Price Index; and

 

(7)  Pays the monthly premium, established pursuant to He-C 5003.

 

(b)  To be considered employed for pay, an individual shall:

 

(1)  Receive remuneration and contribute to the Federal Insurance Contributions Act (FICA); and

 

(2)  Not be paid for participation in a program designed to enhance an individual’s ability to obtain paid employment.

 

(c)  To be considered self-employed for pay, an individual shall:

 

(1)  Meet the requirements of (b)(2) above; and

 

(2)  Provide documentation that he or she makes regular payments based on earnings as required pursuant to the Self-Employment Contributions Act (SECA).

 

(d)  The items listed below shall not be counted as a resource when determining MEAD eligibility:

 

(1)  Retirement plans;

 

(2)  Medical savings accounts established pursuant to 26 USC 220; and

 

(3)  MEAD employability accounts specifically designated and set aside by the individual for the purpose of purchasing certain goods or services that:

 

a.  Will enhance an applicant’s employability; and

 

b.  Are not:

 

1.  Covered by the Medicaid program;

 

2.  Otherwise reimbursable;

 

3.  Specifically excluded pursuant to He-W 856; or

 

4.  Already allowed as a deduction pursuant to He-W 654 or He-W 854.

 

(e)  Goods or services for which MEAD employability accounts may be designated and set aside pursuant to (d)(3) above shall include, but not be limited to:

 

(1)  Equipment, supplies, operating capital, and inventory required to establish a business;

 

(2)  Any cost associated with an educational or occupational training facility, including, but not limited to, tutoring, or counseling;

 

(3)  Work-related attendant care services to enable the individual to prepare for work, including, but not limited to, bathing and dressing, or services provided in the workplace;

 

(4)  Medical devices, which enable the applicant to work, including, but not limited to:

 

a.  Wheelchairs;

 

b.  Prosthetics;

 

c.  Pacemakers; and

 

d.  Respirators;

 

(5)  Equipment or tools either specific to an applicant's condition or designed for general use;

 

(6)  Uniforms, specialized clothing, and safety equipment;

 

(7)  Least costly transportation cost(s) to and from work, such as weekly or monthly bus passes;

 

(8)  Purchase of a private vehicle;

 

(9)  Operational or accessibility modifications to buildings or vehicles to accommodate disability;

 

(10)  Routine drugs or medical services to ameliorate disability that are not covered by Medicaid;

 

(11)  Diagnostic procedures related to evaluation, control, or treatment of a disabling condition;

 

(12)  Prescribed non-medical appliances and devices essential for controlling the disabling condition at home or work such as air filtering equipment;

 

(13)  Expendable medical supplies; and

 

(14)  Guide dogs, dog food, licenses, and veterinary services.

 

(f)  If an applicant uses funds in a MEAD employability account for items other than those described in He-W 841.03(d)(3), the remaining funds in the account shall be counted as a resource.

 

(g)  Applicants who have been determined eligible for medical assistance pursuant to He-W 841.03(a) and who subsequently become unemployed but who intend to return to work shall remain eligible for MEAD for a 6-month extension period beginning with the date the individual becomes unemployed, if:

 

(1)  The recipient was involuntarily terminated from employment, or seasonal work ended, and is currently seeking new employment; or

 

(2)  The recipient voluntarily terminated employment with good cause in accordance with (i) below.

 

(h)  A recipient who has completed the 6-month extension may obtain one additional 6-month extension if the recipient provides either:

 

(1)  A doctor’s written statement regarding the individual’s medical condition as it relates to their inability to work; or

 

(2)  Written documentation of proven job search through contacts made to employers, and/or employment agencies such as One-Stops, Vocational Rehabilitation, or Employment Networks.

 

(i)  The division of family assistance shall determine that good cause for leaving employment exists, in accordance with RSA 167:82, III(c)(1), (2), (4), (6), (7), and (8).

 

(j)  A recipient shall be terminated from MEAD when 3 consecutive occurrences of employment by a recipient indicate that the date of hire occurred during the last month of each of the 6-month periods.

 

Source.  #13380, eff 5-25-22

 

PARTS He-W 838 through He-W 843 – RESERVED

 

PART He-W 844  Technical Requirements for Adult Medical Assistance

 

          He-W 844.01  Personal Interview.

 

          (a)  A personal interview between the individual or authorized representative (AR) and a department staff member or contracted employee shall be required for:

 

(1)  Each initial determination of eligibility for adult category medical assistance; and

 

(2)  Each regularly scheduled redetermination of eligibility for all adult category individuals except for:

 

a.  Individuals who receive in and out medically needy medical assistance pursuant to He-W 878.01;

 

b. Individuals residing in independent living arrangements and not receiving SNAP benefits; and

 

c.  Individuals residing in nursing facilities or swing-bed hospitals, as defined in 42 CFR 413.114(b), and receiving payments for nursing care or who are only eligible for medical services other than a payment for nursing care.

 

          (b)  When required for nursing facility, choices for independence (CFI), home and community-based care for the developmentally disabled (HCBC-DD), home and community-based care for individuals with an acquired brain disorder (HCBC-ABD), and home and community-based care for in-home supports (HCBC-IHS) cases, a department staff member shall conduct a personal interview with one or more of the following:

 

(1)  The individual;

 

(2) A representative of the nursing facility or swing-bed hospital as defined in 42 CFR 413.114(b); or

 

(3)  The individual’s relative or AR.

 

          (c)  A personal interview shall be conducted for all adult category cases, including those exempted above in (a)(2), as a result of reported changes or the discovery of conflicting information related to eligibility.

 

          (d)  A personal interview shall be required once during a 12-month period for any adult category case on a more frequent redetermination of assistance schedule pursuant to He-W 684.02(d).

 

          (e)  The individual or the individual’s AR shall review the summary of the information provided during the interview with the department’s representative who conducted the interview, and:

 

(1)  Make any corrections to the information; and

 

(2)  Sign the summary attesting to the truthfulness and accuracy of the information provided.

 

Source.  #12714, eff 1-23-19

 

PARTS He-W 845 through He-W  847 – RESERVED

 

PART He-W 848  RESIDENTIAL CARE FACILITIES AND COMMUNITY RESIDENCES

 

          He-W 848.01  RESERVED

 

          He-W 848.02  Residential Care Facilities.

 

          (a)  Individuals living in residential care facilities, as described in RSA 151:2, I(e), shall meet all general, technical, categorical, and financial requirements for adult category medical assistance, in addition to the requirements below.

 

          (b)  Individuals living in residential care facilities shall be entitled to a different standard of need than individuals residing in independent living arrangements when the residential care facility is licensed by the department as meeting the standards for the care of residential care facility residents.

 

          (c)  Financial eligibility for individuals in residential care facilities shall be determined as an assistance group size of one.

 

(d)  The standard of need for an individual in a residential care facility shall be adjusted annually as specified in He-W 648.04.

 

Source.  #12179, eff 5-23-17

 

          He-W 848.03  Community Residences.

 

          (a)  Individuals living in community residences, as defined in He-M 1001.02(k), shall meet all general, technical, categorical, and financial requirements for adult category medical assistance, in addition to the requirements below.

 

          (b)  Individuals living in community residences shall be entitled to a different standard of need than individuals residing in independent living arrangements when:

 

(1)  The community residence is certified or licensed by the department;

 

(2)  The individual has been determined appropriate for community residence care by a division of developmental services area agency case manager; and

 

(3)  The individual has been placed in a community residence.

 

          (c)  Financial eligibility for individuals in community residences shall be determined as an assistance group size of one.

 

          (d)  The standard of need shall be adjusted annually, as specified in He-W 648.04, for individuals living in:

 

(1)  Community residences, as defined in He-M 1001.02(k); and

 

(2)  Family residences, as defined in He-M 1001.02(k) and He-M 1001.02(p).

 

Source.  #12179, eff 5-23-17

 

PARTS He-W 849 –through He-W 851  RESERVED

 

PART He-W 852  INCOME – BASIC PRINCIPALS

 

          He-W 852.06  Fluctuating Income.

 

          (a)  "Best estimate" means an expectation of income to be received by an individual determined by evaluating past, present, and anticipated significant and non-significant income changes.

 

          (b)  "Fluctuating income" means:

 

(1)  Earned income that varies from month to month such as when an individual works varying hours, overtime, or on a piece work basis; or

 

(2)  Unearned income that varies from month to month due to changes in frequency or amount.

 

          (c)  "Non-significant changes" means any temporary or short-term variations in the amount of earned or unearned income caused by a situation which is not ongoing.

 

          (d)  "Significant changes" means changes in sources or amounts of earned or unearned income which are:

 

(1)  Expected to continue into the future; or

 

(2)  Short-term because it is caused by a situation which is not ongoing.

 

          (e)  The department of health and human services (DHHS) shall convert fluctuating income to a monthly amount pursuant to He-W 652.05 by averaging income for the most recent consecutive 4 weeks when such income represents a best estimate of future income pursuant to (a) above as verified by pay stubs or a statement from the employer.

 

          (f)  Income received during weeks with non-significant income changes pursuant to (c) above shall not be used to determine the average monthly amount.

 

          (g)  When the average monthly amount determined in (e) above does not represent a best estimate of future income pursuant to (a) above, the average monthly amount shall be determined as follows:

 

(1)  Only data for weeks that accurately represent past earnings, up to a maximum of 8 weeks’ data, shall be included;

 

(2)  The average weekly income shall be determined using the data from the weeks identified in (g)(1) above; and

 

(3)  The appropriate multiplier under He-W 652.05 shall be used to convert average weekly income to a monthly amount.

 

          (h)  When income has been received for less than 4 consecutive weeks, the best estimate of future income pursuant to (a) above, shall be determined by computing a monthly average based on the actual number of weeks the income was received.

 

          (i)  The following shall apply to self-employment income:

 

(1)  If self-employment income is the only income received from employment in a 12-month period, it will be averaged over a 12-month period;

 

(2)  If self-employment income is the only income received from employment in a period of fewer than 12 months, it will be averaged over the number of months it was received; and

 

(3)  If self-employment income is not the only income received from employment, it will be treated as income in the months received and will not be averaged.

 

          (j)  The estimated average monthly gross earned income as defined in He-W 601.04(m), shall be used until the next redetermination of eligibility.

 

          (k)  The estimated average monthly gross earned self-employment income as defined in He-W 601.04(n), shall be used for one year.

 

Source.  #12616, eff 8-30-18

 

          He-W 852.07  Developing Potential Sources of Income or Benefits.

 

          (a)  To be eligible for adult category medical assistance, an individual shall apply for all potential sources of income or benefits, including, but not limited to:

 

(1)  Benefits described under Title II of the Social Security Act;

 

(2)  Veteran's benefits, including the veteran's affairs aid and attendance allowance;

 

(3)  Retirement benefits or pensions;

 

(4)  Disability benefits or pensions;

 

(5)  Unemployment or worker's compensation;

 

(6)  Contributions from any liable third-party; and

 

(7)  Third-party medical coverage.

 

          (b)  The application for other income or benefits described in (a) above shall be made no later than 30 days after the referral for those benefits.

 

          (c)  If the individual is incapable of applying for the aid and attendance allowance pursuant to (a)(2) above, does not have an authorized representative to apply on the individual's behalf, and the nursing facility will not apply on the individual's behalf, the eligibility worker shall initiate the application for the aid and attendance allowance on the individual's behalf.

 

          (d)  When applying for the other income or benefits described in (a) above, applicants and recipients of adult category medical assistance shall:

 

(1)  Provide all required information and verification and complete all forms as required in the application process for the other income or benefits;

 

(2)  Cooperate with the eligibility-determining agencies or the sources of the other income or benefits in taking all necessary steps to obtain the other income or benefits, subject to the limitations in (d)(4) below;

 

(3)   the other income or benefits, if eligible;

 

(4)  Pursue all appeal options within the timeframes set by the eligibility-determining agencies or the sources of the other income or benefits described in (a) above, up to, but not including, court action, if found ineligible for the benefit due to medical reasons; and

 

(5)  Be exempt from developing potential sources of other income or benefits if good cause exists in accordance with (f) and (g) below.

 

          (e)  Medical assistance for all the adults in the assistance group shall be denied or terminated if an individual is ineligible for the other income or benefits described in (a) above due to refusal or failure to comply with the requirements of (d) above.

 

          (f)  If determined to have good cause pursuant to (g) below, an adult category medical assistance applicant or recipient shall be exempt from developing potential sources of other income or benefits until the individual's next redetermination, at which time the exemption shall be reviewed and, if the individual continues to have good cause pursuant to (g) below, the exemption shall be extended until the next regularly scheduled redetermination.

         

          (g)  An adult category medical assistance applicant or recipient shall be determined to have good cause if the individual verifies that a physical, mental, educational, or linguistic limitation prevented the individual from:

 

(1)  Applying for the other income or benefits described in (a) above; or

 

(2)  Taking other necessary steps to obtain the other income or benefits, as described in (d) above.

 

Source.  #13121, eff 10-21-20

 

PART He-W 853  RESERVED

 

PART He-W 854  EVALUATION AND TREATMENT OF INCOME

 

          He-W 854.02  Income Computation.

 

          (a)  In computing eligibility and benefits, if any subtraction results in a negative amount, the result shall be considered to be zero instead of the negative amount.

 

          (b)  For individuals not living in nursing facilities who are applying for or receiving adult category medical assistance, and, if applicable, their applicant spouses, as defined in He-W 601.01(o), net income, as defined in He-W 601.05(v), shall be computed as follows:

 

(1)  The amount of the individual’s and the individual’s applicant spouse’s countable gross earned income, as defined in He-W 601.04(m)-(n), shall be determined;

 

(2)  For each individual, the earned income disregard for the adult category under which each individual is applying or receiving assistance, as specified in He-W 654.15, shall be computed and subtracted from each individual’s countable gross earned income to obtain each individual’s net earned income, as defined in He-W 601.05(u);

 

(3)  The individual net earned income amounts shall be added together to obtain the assistance group’s (AG’s) net earned income amount;

 

(4)  The countable gross unearned income, as defined in He-W 601.08(k), of each individual shall be added to the AG’s net earned income;

 

(5)  From the total in (4) above, the adult standard disregard, as specified in He-W 854.16, and allowable deductions, as specified in He-W 854.20 and He-W 654.21, shall be subtracted; and

 

(6)  The result shall be the AG’s net income.

 

          (c)  For individuals not living in nursing facilities who are applying for or receiving APTD or OAA medical assistance, and who live with their nonapplicant spouses, as defined in He-W 601.05(x), net income, as defined in He-W 601.05(v), shall be computed as follows:

 

(1)  The countable gross earned incomes of the applicant and nonapplicant spouse shall be combined;

 

(2)  The earned income disregard shall be subtracted from the combined gross earned income determined in (1) above to obtain the AG’s net earned income, except as follows:

 

a.  For APTD medical assistance applicants, allowable impairment related work expenses (IRWEs), as described in 20 CFR 416.1112, shall be subtracted from the gross earned income of the applicant only, and not subtracted from the gross earned income of the nonapplicant spouse; and

 

b.  For OAA medical assistance recipients, the IRWE deduction shall be subtracted only when the recipient’s case is transferred from APTD medical assistance to OAA medical assistance;

 

(3)  The countable gross unearned income, as defined in He-W 601.08(k), of all AG members shall be added to the AG’s net earned income amount determined in (2) above;

 

(4)  From the total in (3) above, the adult standard disregard, as specified in He-W 854.16, and allowable deductions, as specified in He-W 854.20 and He-W 654.21, shall be subtracted; and

 

(5)  The result shall be the AG’s net income as defined in He-W 601.05(v).

 

          (d)  For individuals applying for or receiving ANB medical assistance who live with their nonapplicant spouses as defined in He-W 601.05(x), eligibility and level of benefits shall be computed as in (c) above, except that the individualized plan for employment work expenses subtracted from the applicant’s earned income shall be those described in He-W 654.15(d).

 

          (e)  For individuals living in nursing facilities who are applying for or receiving OAA, APTD or ANB, gross income for purposes of determining categorical eligibility for nursing facility care, as defined in He-W 858.05, shall be computed by adding together the individual’s countable gross earned income and countable gross unearned income.

 

          (f)  The amount of an individual’s net income for purposes of determining eligibility for nursing facility care as medically needy, as defined in He-W 858.05, shall be computed as follows:

 

(1)  The earned income disregard for the adult category under which the individual is applying for or receiving assistance, as defined in He-W 654.15, shall be subtracted from the individual’s countable gross earned income to obtain the individual’s net earned income;

 

(2)  The individual's countable gross unearned income shall be added to the net earned income; and

 

(3)  The allowable deductions, as specified in He-W 854.20 and He-W 654.21, shall be subtracted, in order, from the amount in (2) above to arrive at the individual’s net income as defined in He-W 601.05(v).

 

Source.  #12050, eff 11-19-16

 

            He-W 854.15  Adult Category Earned Income Disregard.

 

          (a)  The earned income disregard shall be the first subtraction from earned income when computing net income for the adult categories of medical assistance.

 

          (b)  For aid to the permanently and totally disabled (APTD) or old age assistance (OAA) medical assistance applicants and recipients and for their applicant spouses who are also applying for APTD or OAA medical assistance, the earned income disregard for each individual shall consist of the amounts specified in 20 CFR 416.1112 for supplemental security income (SSI) recipients.

 

          (c)  For aid to the needy blind (ANB) medical assistance applicants and recipients and for their applicant spouses who are also applying for ANB, the earned income disregard for each individual shall be the first $85.00 of each individual's monthly gross earned income plus one half of the remaining amount.

 

          (d)  ANB medical assistance applicants and recipients shall have additional employment-related amounts added to the earned income disregard if:

 

(1)  There is an individualized plan for employment for a specified period of time which has been approved by the New Hampshire department of education and meets the requirements cited in 29 USC 720 et. seq.; and

 

(2)  The plan described in (1) above requires the use of additional disregards.

 

          (e)  For ANB medical assistance applicants and recipients with applicant spouses who are applying for APTD or OAA, the computation method for determining the amount of the earned income disregard for the spouse shall be the method to determine the APTD or OAA earned income disregard in (b) above for medical assistance.

 

          (f)  For APTD or OAA medical assistance applicants and recipients with applicant spouses who are applying for ANB, the computation method for determining the amount of the earned income disregard for the spouse shall be the method to determine the ANB earned income disregard in (c) and (d) above.

 

          (g)  For an adult category assistance group which includes a non-applicant spouse, as defined in He-W 601.05(t), the computation method for determining the amount of the earned income disregard to be applied to the medical assistance case shall be the method specified in 20 CFR 416.1112(c) for SSI recipients.

 

Source.  #13525, eff 1-24-23

 

He-W 854.16  Adult Standard Disregard.

 

(a)  For medical assistance applicants or recipients who do not reside in nursing facilities, a standard disregard shall be subtracted from income as described in He-W 654.02(c)(5).

 

(b)  The amount of the disregard shall depend on the number of individuals whose needs are considered when determining eligibility, as follows:

 

(1)  The standard disregard for one individual shall be $13.00;

 

(2)  The standard disregard shall be $20.00 for an individual and applicant or nonapplicant spouse, or an individual and a needy essential person; and

 

(3)  The standard disregard shall be $25.00 for an individual and applicant or nonapplicant spouse and a needy essential person.

 

Source.  #11042, eff 2-24-16

 

          He-W 854.17  Post-Eligibility Computation of Cost of Care for Nursing Facility Care.

 

          (a)  The amount of income that an eligible individual residing in a nursing facility is liable to contribute toward the cost of his or her nursing facility care shall be computed as follows:

 

(1)  The amount of the applicant or recipient’s gross earned income as defined in He-W 601.04(m) shall be determined;

 

(2)  The employment expense disregard, as specified in He-W 654.18, shall be subtracted from the individual's gross earned income to obtain the individual’s net earned income;

 

(3)  The total amount of the individual's unearned income, as defined in He-W 601.08(k), shall be added to the net earned income to determine the individual’s net income;

 

(4)  The allowable deductions, as defined in He-W 854.20 and He-W 654.21, shall be subtracted from the individual’s net income;

 

(5)  The veterans affairs nursing facility pension, as defined in 38 U.S.C. 5503, if received, or the personal needs allowance, as described in (b) below, shall be subtracted from the amount in (4) above;

 

(6)  The amount of income to be allocated to a spouse or dependents, as described in He-W 654.21, shall be subtracted from the amount in (5) above;

 

(7)  The cost of the following medical expenses incurred by the recipient shall be subtracted from the amount in (6) above:

 

a. Health insurance premiums, including Medicare Part B, coinsurance payments, and deductibles;

 

b.  Necessary and remedial care that would be covered by medical assistance except that allowable payment limits have been exceeded;

 

c.  Necessary and remedial care that is recognized by state law, but not covered by medical assistance; and

 

d.  Currently obligated, unpaid prior medical debt;

 

(8)  The amount of any continuing SSI benefits, under 42 USC 1382(e), shall be subtracted from the amount in (7) above;

 

(9)  If a physician has verified the stay in the nursing facility is to be 3 months or less and the individual is expected to return home, an amount equal to the FANF shelter payment allowance, as described in He-W 658.02, shall be subtracted from the amount in (8) above;

 

(10)  The veterans affairs aid and attendance allowance shall be added to the amount in (8) or (9) above as required by 42 CFR 435.733(c); and

 

(11)  The result in (10) above shall be the amount of income for which the individual is liable to remit to the nursing facility as payment toward the cost of his or her nursing facility care.

 

          (b)  The personal needs allowance (PNA) shall be equal to the minimum amount mandated by RSA 167:27-a, I and, pursuant to RSA 167:27-a, II, updated every 5 years by:

 

(1)  Multiplying the current year’s PNA by the sum of the previous 5 years’ cost of living adjustments as described in 20 CFR 416.405;

 

(2)  Rounding up the product derived in (b)(1) above to the next whole dollar; and

 

(3)  Adding the rounded up product in (b)(2) above to the current year’s PNA.

 

          (c)  For all individuals applying for nursing facility care:

 

(1)  Only the following currently obligated, unpaid prior medical debts shall be allowed:

 

a.  Non-nursing facility-related medical expenses; and

 

b.  Nursing facility expenses at the Medicaid provider payment rate for the facility.

 

(2)  Nursing facility expenses incurred during any penalty period pursuant to He-W 601.06(h), or period of ineligibility pursuant to He-W 601.06(i), except as noted in (c)(3) below, shall not be considered an allowable medical debt pursuant to (a)(7)(d) above; and

 

(3)  Nursing facility expenses incurred during a period of ineligibility due to excess resources or receipt of a lump sum shall be considered an allowable medical expense pursuant to (a)(7)d. above, and in accordance with (c)(1)b. above.

 

Source.  #11042, eff 2-24-16 (formerly He-W 654.17)

 

          He-W 854.18  Adult Employment Expense Disregard.

 

          (a)  Expenses which are reasonably attributable to the earning of income shall be subtracted from the earned income of individuals living in nursing facilities who are receiving OAA, APTD or ANB when determining the amount of the individual’s cost of care liability as defined in He-W 854.17.

 

          (b)  The amount of the employment expense disregard shall be either a flat rate of $18.00 per month, or the amount of actual verified expenses if higher than $18.00 per month.

 

          (c)  The following expenses, if actually incurred and verified, shall be considered reasonably attributable to the earning of income:

 

(1)  Social security taxes, at the rate set by SSA;

 

(2)  Railroad retirement taxes;

 

(3)  Federal withholding taxes, corresponding to the number of exemptions which the individual is legally entitled to claim;

 

(4)  Mandatory retirement payments;

 

(5)  Mandatory union dues;

 

(6)  Other mandatory deductions from wages provided that the individual can document that the payroll deduction is not elective;

 

(7)  Costs for transportation to and from work or to and from child care when child care is necessary for employment, subject to the following conditions:

 

a.  To qualify as an allowable employment expense, the transportation used shall be the least expensive reasonable means available to the individual;

 

b.  The amount of allowable transportation costs shall be computed by multiplying the average number of days per month an individual is employed, without deducting temporary absences of short duration, by the transportation cost for one day;

 

c.  If the individual has been or will be reimbursed for transportation costs in any manner, the amount of the reimbursement shall be subtracted from the amount that would otherwise be allowed;

 

d.  For travel incurred by an individual using his or her own vehicle, the allowable transportation cost shall be $0.21 per mile multiplied by the number of miles anticipated to be traveled in a month;

 

e. For travel provided in another person's privately owned vehicle, the allowable transportation cost shall be as charged up to the amount that would be allowed if the individual used his or her own vehicle; and

 

f.  For travel provided by public transportation, such as by taxi or bus, the allowable transportation cost shall be the amount charged the public for such travel;

 

(8)  Costs for uniforms and other unique clothing required for employment and not worn outside the work environment, subject to the following conditions:

 

a. Cleaning of uniforms shall not be an allowable employment expense unless the individual can document that a standard of cleanliness requires professional cleaning as a condition of employment;

 

b.  The allowable expense shall be the amount actually paid by the individual for the special clothing;

 

c.  If the amount varies monthly, an average shall be computed and applied until the next regularly scheduled redetermination; and

 

d.  If the individual has been or will be reimbursed in any manner for a claimed special clothing expense, the reimbursed amount shall be subtracted from the amount which would otherwise be allowed; and

 

(9)  Other mandatory employment related expenses claimed and verified by the individual.

 

Source.  #12050, eff 11-19-16

 

          He-W 854.20  Allowable Deductions.

 

          (a)  When determining eligibility and the amount of assistance for all categories of medical assistance, an allowable deduction from the income available to the assistance group shall be made, in an amount which has been or must be paid by an individual for non-employment-related types of expenses, including the following:

 

(1)  Training expenses as described in (e) below;

 

(2)  Garnishments from an individual’s earnings to repay a legal debt;

 

(3)  Allocated income, as specified in He-W 654.21; and

 

(4)  Any court-ordered payments, as described in (f) below, including but not limited to child support, alimony, and guardianship fees.

 

          (b)  The deduction described in (a) above shall be allowed for:

 

(1)  Any individual whose needs are included in the assistance group; and

 

(2)  Any individual whose income is counted even if his or her needs are not included in the assistance group.

 

          (c)  The amount of the deduction shall be the amount of the verified expense.

 

          (d)  Allowable deductions shall be applied as follows:

 

(1)  For medical assistance non-nursing facility cases in which there is a nonapplicant spouse, the allowable deductions shall be subtracted from the amount which represents the monthly combined earned income, less all applicable disregards to earned income as described in He-W 654.14 and He-W 654.15, plus all unearned income;

 

(2)  For adult category non-nursing facility cases in which there is an applicant spouse, the allowable deductions shall be subtracted from the amounts which represent the individual monthly net incomes of the applicant and the applicant spouse; and

 

(3)  For nursing facility cases, allowable deductions shall not be subtracted for the categorically needy eligibility determination as described in He-W 654.02, but shall be the first subtraction from the net income amount for the medically needy eligibility determination as described in He-W 654.02.

 

          (e)  Training expenses shall be an allowable deduction when all the following circumstances are met:

 

(1)  The individual is enrolled in and regularly attending at least on a half-time basis, a program having an organized curriculum with the specific objective of training individuals for gainful employment;

 

(2)  The training program is sponsored by public education or the federal government, or is offered by private schools for a particular trade;

 

(3)  The individual has not received reimbursement for the training expense from any other source, or if partial reimbursement is made, the remaining expense shall be an allowable deduction;

 

(4)  The training expense is not part of an employment expense disregard, because the individual has no earned income, or the training is totally unrelated to the individual's employment; and

 

(5)  The expense occurs on at least a monthly basis.

 

          (f)  Any court-ordered payment which must be paid by an individual shall be an allowable deduction, regardless of whether the individual actually makes the payment.

 

Source.  #11042, eff 2-24-16

 

PART He-W 855  RESERVED

 

PART He-W 856  RESOURCES

 

He-W 856.01  Resources - Basic Principles.

 

(a)  Except where otherwise provided or specifically prohibited by federal law, resources shall be evaluated and treated the same for all categories of medical assistance that use a resource test in the eligibility determination process.

 

(b)  The department's state spousal resource standard shall be the minimum standard required by 42 USC 1396r-5(f) and (g).

 

(c)  As required by 42 USC 1396r-5(e)(2)(C), there shall be substituted for the community spouse resource allowance, pursuant to 42 USC 1396r-5(f)(2), an amount adequate to raise the community spouse's income up to the maximum maintenance allowance if all of the following conditions are met:

 

(1)  The institutionalized spouse has allocated the maximum amount of income allowed pursuant to He-W 654.21(h); and

 

(2)  An administrative appeals officer determines that the community spouse resource allowance, in relation to the amount of income generated by such an allowance, is inadequate to raise the community spouse's income to the maximum maintenance allowance specified in 42 USC 1396r-5(d).

 

(d)  For purposes of evaluating and treating resources, individuals applying for or receiving home and community based care shall not be considered institutionalized individuals except when evaluating asset transfers.

 

Source.  #10924, eff 10-1-15

 

          He-W 856.02  Treatment of Specific Types of Resources.  Funds from an individual development account used for unqualified purposes, pursuant to 42 USC 604(h), shall be treated as lump sum payment in accordance with He-W 656.04(b)(10), for the adult categories of medical assistance.

 

Source.  #12481, eff 2-21-18

 

He-W 856.03  Jointly Owned Resources.

 

(a)  Personal property resources established prior to November 1, 1995, which an individual owns together with a non-assistance group member who is not receiving assistance, shall be considered to be shared equally among the owners, unless the individual verifies ownership of more or less than an equal share.  If the individual verifies ownership of more or less than an equal share through documentary evidence, only the amount of the share actually owned by the individual shall count as a reSource.

 

          (b)  Personal property resources established on or after November 1, 1995, which an individual owns together with an individual who is not an applicant or recipient, shall be considered to belong to the individual who is applying for or receiving assistance.  If there is more than one individual who is applying for or receiving assistance that jointly owns the resource, it shall be assumed that each individual owns an equal share.

 

(1)  If an individual wishes to rebut the ownership presumption in (b) above, the individual shall submit to the department all of the following:

 

a.  A statement from the individual describing the portion of the personal property resources the individual claims to own, signed and dated under penalty of unsworn falsification pursuant to RSA 641:3;

 

b.  A corroborating statement from each other account holder, with each statement signed and dated under penalty of unsworn falsification pursuant to RSA 641:3;

 

c.  If the only other account holder is incompetent or a minor, a corroborating statement from a competent adult aware of the circumstances surrounding establishment of the account;

 

d.  Account records showing deposits, withdrawals and interest in the months for which ownership is an issue;

 

e.  If the individual does not own any of the funds, documentary evidence showing that the individual can no longer withdraw funds from the account; and

 

f.  If the individual owns only a portion of the funds, documentary evidence showing removal from the account of such funds, or removal of the funds owned by the other account holder(s), and redesignation of the account.

 

(2)  Any resources that the evidence establishes were owned by the other account holder(s), as determined by the department, and that the individual can no longer withdraw from the account shall not be considered to be the individual's resources.  However, such resources shall be deemed available to the individual if the account holder to whom they belong is someone whose resources would be used in determining the individual's eligibility.

 

(3)  Jointly owned real property shall be excluded if the terms of ownership of the property prevent the individual from unilaterally liquidating the property and the other owner or owners refuse to agree to the sale. The addition of a joint owner shall be evaluated as an asset transfer in accordance with He-W 620.01.

 

(4)  To verify:

 

a.  The terms of ownership of the jointly owned real property which prevent the individual from unilaterally liquidating the property pursuant to (3) above, the individual shall submit to the department the deed, title, or other legally binding property document stating the terms of property ownership; and

 

b.  The other owner or owners refuse to agree to the sale pursuant to (3) above, the individual shall submit to the department a corroborating statement from each other account holder, with each statement signed and dated under penalty of unsworn falsification pursuant to RSA 641:3.

 

Source.  #10982, eff 11-24-15

 

          He-W 856.04  Personal Property Resources.

 

          (a)  For all non-MAGI categories of medical assistance except as specified in (11) and (12) below, personal property resources shall be treated as follows:

 

(1)  At application and redetermination, the assistance group shall report and verify all resources;

 

(2)  The value of accumulated interest, the equity value of life insurance policies and the value of stocks and bonds, when verified at application or redetermination, shall be considered unchanged until the next redetermination;

 

(3)  Changes to the value of the resources identified in He-W 856.03(a) shall be reported between redeterminations;

 

(4)  Individuals shall report the acquisition of new resources and the selling of existing resources, pursuant to RSA 167:17;

 

(5)  The following resources shall not be counted when determining eligibility:

 

a.  Borrowed money, except for when the individual transfers the proceeds or a portion of the proceeds of the loan to another individual pursuant to He-W 820.03(d)(7);

 

b.  All household items;

 

c.  Inaccessible personal property resources whose value is legally unobtainable by the individual, except as specified in (7) below;

 

d.  Group, term, and fraternal life insurance policies which have no equity value and are only payable upon the death of the insured;

 

e.  Lump sum death payments to cover funeral and burial expenses;

 

f.  Resources resulting from an accumulation of types of income that are excluded by federal mandate;

 

g.  Federal, state, and local income tax refunds; and

 

h.  Keogh accounts which involve a contractual relationship with a non-assistance group member, provided the contract prevents the individual from withdrawing money from the account without affecting the employer or other employees;

 

(6)  All Individual Retirement Accounts (IRA), one-person Keogh accounts, and non-contractual Keogh accounts shall be counted towards the resource limit as follows:

 

a.  The balance in the account minus the penalty for early withdrawal for the entire account shall be counted; and

 

b.  The balance amount and the amount of the penalty for early withdrawal shall be as specified on the date on which they are initially verified and these amounts shall remain in effect until the next redetermination;

 

(7)  Trusts and similar legal devices shall be treated as follows:

 

a.  Trusts and similar legal devices, including annuities, established after August 10, 1993, and trusts and legal devices that were established prior to August 11, 1993 but have been added to or otherwise augmented after August 10, 1993, shall be treated in accordance with 42 USC 1396p(d)(1)-(3);

 

b.  No clause or requirement in the trust, no matter how specifically it applies to  state or federal programs, shall preclude a trust from being considered in accordance with 42 USC 1396p(d)(1)-(3);

 

c.  Any payments from revocable trusts, which are not made to, or on behalf of, the individual shall be considered assets disposed of for less than fair market value pursuant to He-W 820;

 

d.  Payments of income or payments from the corpus of irrevocable trusts that are not made to or for the benefit of the individual, shall be treated as a transfer of assets for less than fair market value pursuant to He-W 820;

 

e.  Irrevocable trusts where payments from some portions or all of the trust cannot under any circumstances be made to, or for the benefit of, the individual shall be treated as follows:

 

1.  The portion of the corpus or income on the corpus which cannot be paid to the individual shall be treated as a transfer of assets and shall be treated in accordance with He-W 820;

 

2.  In treating portions of the corpus or income which cannot be paid to the individual as a transfer of assets, the date of the transfer shall be the date the trust was established or, if later, the date on which payment to the individual was restricted or eliminated;

 

3.  In determining the value of the portion of the trust which cannot be paid to the individual for transfer purposes, any payments made, for whatever purpose, after the date the trust was established or, if later, the date payment to the individual was foreclosed, shall not be subtracted from the value of the trust;

 

4.  If funds were added to that portion of the trust after these dates, those funds shall be considered to be a new transfer of assets, effective on the date the funds are added to the trust; and

 

5.  The value of the transferred amount shall be no less than its value on the date of establishment or the date that access to the principal of the trust was restricted or eliminated;

 

f.  When some portion of the corpus or income on the corpus of a trust is or can be paid to the individual, such portion or income shall be treated in accordance with the standards set forth in 42 USC 1396p(d)(3)(A) or (B), as applicable;

 

g.  Payments shall be considered to be made to the individual when any amount from the trust, including an amount from the corpus, or income produced by the corpus, is paid directly to the individual, or to someone acting on the individual's behalf; and

 

h.  Payments made for the benefit of the individual shall be payments of any sort, including an amount from the corpus, or income produced by the corpus, paid to another entity such that the individual derives some benefit from the payment;

 

(8)  An irrevocable burial trust established by an individual for the purpose of paying, at some point in the future, for the various expenses associated with the individual's funeral and burial shall be an exempt trust if the individual has a signed contract with a funeral home and the corpus of the trust does not exceed the contracted amount;

 

(9)  Annuities shall be excluded from the resource computation only if all of the following are true:

 

a.  The expected return on the annuity is commensurate with the life expectancy of the beneficiary in accordance with He-W 820.03(l);

 

b.  The annuity is owned by an individual applying for medical assistance on or after November 1, 2003, and the state of New Hampshire is selected as the:

 

1.  Contingent beneficiary in the event that the individual’s spouse, minor child, or permanently and totally disabled child, if any, predeceases the individual; or

 

2.  Secondary beneficiary if the individual has no spouse, minor child, or permanently and totally disabled child at the time the annuity is purchased; and

 

c.  The annuity is owned by an individual applying for medical assistance on or after November 1, 2003, and the payment structure provides equal or nearly equal payments to the individual for the duration of the annuity;

 

(10)  Annuities excluded from the resource computation pursuant to (9) above shall be treated as follows:

 

a.  When an individual cannot access the principal of an annuity, the annuity shall be treated as an irrevocable trust;

 

b.  If an annuity provides for payments to be made to the individual, those payments shall be considered unearned income to the individual;

 

c.  Any portion of the principal of the annuity that is paid to or on behalf of the individual shall be considered unearned income to the individual; and

 

d.  Portions of the annuity that cannot be paid to or for the benefit of the individual shall be treated as transfers of assets and shall be evaluated in accordance with He-W 820;

 

(11)  Trusts described in 42 USC 1396p(d)(4)(A) shall continue to be excluded when determining eligibility for medical assistance-only even after the individual becomes age 65, except that any addition to the trust or augmentation of the trust after the individual turns age 65 shall be treated as a transfer of assets for less than fair market value;

 

(12)  Trusts described in 42 USC 1396p(d)(4)(C) shall include a provision specifically providing for payment to the state pursuant to 42 USC 1396p(d)(4)(C)(iv); and

 

(13)  Where application of the trust provisions discussed in 42 USC 1396p(d)(4)(A) and (C) would cause an undue hardship as specified in He-W 821.01(a)(6), those provisions shall not apply.

 

          (b)  For the adult categories of medical assistance, personal property resources, with the exception of additional resources of individuals eligible for medicaid for employed adults with disabilities (MEAD) pursuant to He-W 841.03, shall be treated as follows:

 

(1)  The following resources shall not be counted when determining eligibility for the adult categories of medical assistance:

 

a.  All vehicles such as but not limited to cars, trucks, boats, motorcycles and snowmobiles; and

 

b.  Farm machinery, livestock, tools, and equipment;

 

(2)  The equity value of the following resources shall be counted when determining eligibility for all adult categories of medical assistance:

 

a.  Bank accounts, including checking accounts;

 

b.  Stocks and bonds; and

 

c.       Pre-paid debit card, such as Direct Express card;

 

(3)  Accessible burial funds shall be treated in the following manner:

 

a.  Up to $1500 of the burial funds shall not be counted when determining eligibility for the adult categories of medical assistance when the value of the burial funds, added to the individual’s other countable resources, exceeds the resource limits as specified in He-W 856.06;

 

b.  The amount of the burial fund exclusion shall be reduced by:

 

1.  The combined face value of any life insurance policies; and

 

2.  Any irrevocable trusts or irrevocable funds identified as available to meet burial expenses;

 

c.  Interest earned on excluded burial funds and appreciation on the value of excluded burial arrangements shall be excluded as a resource, if left to accumulate as part of the separately identified burial fund;

 

d.  Interest earned on any portion of the burial fund not excluded as a resource shall be excluded only if inaccessible to the individual; and

 

e.  Accumulated interest which is accessible to the individual shall be counted as a resource at each eligibility determination;

 

(4)  Resources set aside under an SSA-approved PASS shall be excluded for the duration of the plan;

 

(5)  Life insurance policies shall be:

 

a.  A countable resource when the combined equity value of all an individual’s policies exceeds $1,500; or

 

b.  An excluded resource when:

 

1.  The total combined equity value of all the individual’s policies is equal to or less than $1,500; or

 

2.  The combined equity value of the individual’s policies exceeds $1,500, but the state of New Hampshire has been made the beneficiary to the policies pursuant to RSA 167:4, IV(c);

 

(6)  Applicants whose life insurance policies have a combined face value exceeding $1,500 shall be allowed to offset the excess equity value of life insurance for 3 months if:

 

a.  The equity value of life insurance exceeds resource limits in He-W 856.06, but other countable resources do not exceed the resource limits; and

 

b.  The applicant or the applicant's legal spouse who is living with the applicant has incurred and is liable for unpaid medical expenses;

 

(7)  The excess value of life insurance shall be offset as follows:

 

a.  Unpaid medical bills which were incurred before the period for which eligibility is requested shall be deducted from the equity value of the life insurance policies;

 

b.  If there are not enough prior unpaid medical bills to offset the equity value of life insurance, unpaid medical bills incurred within the period of which eligibility is requested shall be deducted from the equity value of the life insurance policies in chronological sequence, starting with the earliest unpaid bill;

 

c.  The medical expense offset shall occur prior to the determination of eligibility for in and out medical assistance described in He-W 878.01; and

 

d.  No incurred unpaid medical bill shall be offset more than once;

 

(8)  The period of offsetting incurred medical expenses shall begin on the date that the applicant provides verification to the department of health and human services (DHHS) of resources and incurred medical expenses, and shall end 3 months thereafter;

 

(9)  At the end of the 3 month period, the equity value of life insurance shall be counted in full without any offset for medical expenses;

 

(10)  Lump sum payments, with the exception of lump sum earned income and excludable lump sum payments paid to cover funeral expenses and portions of third party medical and other expenses directly associated with receipt of the lump sum, shall be counted as a resource when determining eligibility for the adult categories of medical assistance; and

 

(11)  For medical assistance services described in He-W 820.03(s), entrance fees paid to a continuing care retirement community (CCRC) shall be considered available to the individual if:

 

a.  The entrance fee may be used to pay for care;

 

b.  The individual is entitled to a refund when the individual dies or terminates the CCRC; and

 

c.  The entrance fee does not confer an ownership interest in the CCRC.

 

          (c)  For the parents and other caretaker relatives category of medically needy medical assistance, personal property resources shall be treated as follows:

 

(1)  Liquid resources such as bank accounts, stocks, bonds, and savings certificates, owned by an alien's sponsor or sponsor's spouse, shall be deemed to be available to the alien when determining an alien's eligibility for parents and other caretaker relatives category of medically needy medical assistance;

 

(2)  Liquid resources such as vehicles which are owned by an alien's sponsor or sponsor's spouse shall not be deemed to be available to the alien;

 

(3)  Junk vehicles used only to supply parts for the individual's main vehicle, are in such dilapidated condition that they cannot be reasonably repaired for sale or use, or which can only be sold for scrap or parts, and vehicles which are jointly owned with a non-assistance group member, shall be excluded as a resource when determining eligibility for parents and other caretaker relatives category of medically needy medical assistance;

 

(4)  Lump sum payments derived from converting a non-liquid resource to cash shall be counted as a lump sum resource when determining eligibility for parents and other caretaker relatives category of medically needy medical assistance;

 

(5)  The remaining balance of the working checking account and pre-paid debit card on the day it is reviewed, reduced by the amount that represents the FANF payment standard for an assistance group of comparable size with no income, shall be counted as a resource for parents and other caretaker relatives category of medically needy medical assistance;

 

(6)  The following special provisions shall apply to parents and other caretaker relatives category of medically needy medical assistance recipients whose countable resources exceed the allowable limit because their sole resources consist of personal property assets which cannot be readily converted to cash, or which consist of such assets and real property as follows:

 

a.  Recipients shall reduce excess resources to within allowable limits no later than the month following the month in which resources first exceed the limit;

 

b.  The recipient shall verify the recipient is making a good faith effort to sell the personal property resource which caused the resource limit to be exceeded; and

 

c.  Medical assistance shall terminate if the recipient fails to reduce resources within the above time frames;

 

(7)  The equity value of each individual’s life insurance policies shall be counted as a resource when determining eligibility for parents and other caretaker relatives category of medically needy medical assistance, when the total combined value of the policies is greater than $1,500;

 

(8)  For the purposes of the vehicle exclusion specified in RSA 167:81,IV(b), the total number of vehicles excluded as a resource, regardless of ownership or value,  should not to exceed the number of adult members of the assistance group; and

 

(9)  The equity value of all life insurance policies shall be excluded as a resource when determining eligibility for parents and other caretaker relatives category of medically needy medical assistance, when:

 

a.  The combined value of each individual's policies is $1,500 or less; or

 

b.  The total combined value of each individual's policies exceeds $1,500, but the state of New Hampshire has been made the beneficiary to the policies pursuant to RSA 167:4,IV(c).

 

Source.  #13395, eff 6-18-22

 

He-W 856.05  Real Property Resources.

 

(a)  For the adult categories of medical assistance, real property resources shall be treated as follows:

 

(1)  The home occupied by the individual shall not be counted when determining eligibility for adult categories of medical assistance;

 

(2)  An unoccupied home shall not be counted during periods of temporary absence such as short term hospitalization or institutionalization;

 

(3)  Income-producing property, which is real property not occupied by the individual, but producing income at least sufficient to meet the expenses of its ownership and maintenance shall not be counted;

 

(4)  Any real property not otherwise excluded shall not be counted if it is necessary as the residence for the individual’s spouse, minor child, or disabled child;

 

(5)  One burial plot per assistance group member shall not be counted; and

 

(6)  The equity value of real property which is not specifically excluded above shall be counted as a resource when determining eligibility for adult categories of medical assistance, except during the 6 month disposal period described in subsection (b).

 

(b)  For adult categories of medical assistance, the assistance group shall take action to dispose of the property within 6 months of being notified by the department of health and human services (DHHS) that the property must be liquidated, and:

 

(1)  The equity value of the property shall not be counted during the disposal period; and

 

(2)  The disposal period shall be extended as long as:

 

a.  The individual verifies that action has been taken to sell the property and that there are valid reasons for inability to sell the property; or

 

b. The individual’s hospitalization or institutionalization, although long term, is not expected to be permanent and it is likely that the individual will return to the home.

 

(c)  If disposal does not occur within the disposal period, as specified in (b) above, medical assistance shall be denied or terminated.

 

(d)  Applicants and recipients of medical assistance described in He-W 820.01(q), whose equity interest in their primary residence exceeds the 2016 limit of $552,000, updated annually pursuant to 42 USC 1396p(f)(1)(C), shall not be eligible for such services, but shall remain eligible for other medical assistance services, unless the individual’s spouse, minor child or disabled child resides in the property.

 

Source.  #12217, eff 6-22-17

 

          He-W 856.06  Resource Limits.

 

          (a)  The resource limit for categorically needy medical assistance for home care for children with severe disabilities (HC-CSD) shall be $1,000, regardless of assistance group size.

 

          (b)  The resource limit for adult categorically-needy medical assistance shall be $1,500, with the exception of individuals eligible for medicaid for employed adults with disabilities (MEAD) pursuant to He-W 641.03.

 

          (c)  Except as described in (d) below, the resource limit for all categories of medically-needy medical assistance shall be as follows, based on the number of individuals in the assistance group:

 

(1)  For a single individual, $2,500;

 

(2)  For 2 individuals, $4,000; and

 

(3)  For 3 or more individuals, add an additional $100 for each additional individual in the assistance group to the resource limit in (2) above.

 

          (d)  The resource limit for applicants for medical assistance long-term care services shall be $2,500 plus the value of coverage provided in a conforming long-term care insurance policy, pursuant to RSA 167:4, IV(d) and 42 USC 1396p(b).

 

Source.  #12017, eff 10-25-16

 

PART He-W 857  RESERVED

 

PART He-W 858  STANDARD OF NEED

 

Revision Note #1:

 

          Document #11169, effective 8-22-16, readopted with amendments He-W 658.04 titled “Protected Income Level” and renumbered the rule as He-W 858.04.  The source note information for He-W 876.01 prior to Document #11169 includes the documents filed under He-W 658.04.

 

          Although He-W 658.04 had last been filed under Document #9208, effective 7-19-08, this rule did not expire on 7-19-16 since it was extended pursuant to RSA 541-A:14-a until replaced by He-W 858.04 in Document #11169, effective 8-26-16.

 

Revision Note #2:

 

          Document #12050, effective 11-19-16, included among other rules the readoption with amendments of He-W 658.05 titled “Eligibility for Adult Category Medical Assistance Nursing Care” and renumbered the rule as He-W 858.05.  Document #12050 also included the readoption with amendments of He-W 658.06 titled “Eligibility for Adult Category Medical Assistance for Choices for Independence (CFI), Home and Community-Based Care for the Developmentally Disabled (HCBC-DD), Home and Community-Based Care for Individuals with an Acquired Brain Disorder (HCBC-ABD), and Home and Community-Based Care for In-Home Supports (HCBC-HIS)” and renumbered the rule as He-W 858.06, now re-titled as “Eligibility for Adult Category Medical Assistance for Home and Community-Based Care Choices for Independence (HCBC-CFI), Home and Community-Based Care for the Developmentally Disabled (HCBC-DD), Home and Community-Based Care for Individuals with an Acquired Brain Disorder (HCBC-ABD), and Home and Community-Based Care for In-Home Supports (HCBC-HIS)”. 

 

          The source note information for He-W 858.05 and He-W 858.06 prior to Document #12050 includes the documents filed under He-W 658.05 and He-W 658.06, respectively.

 

          Although He-W 658.05 and He-W 658.06 had last been filed as regular rules under Document #9289, effective 10-3-08, these rules did not expire on 10-3-16 since they were extended pursuant to RSA 541-A:14-a until replaced by He-W 858.05 and He-W 858.06 in Document #12050, effective 11-19-16.

 

He-W 858.04  Protected Income Level.

 

(a)  The department shall use a set of standards called the protected income levels (PIL) to determine eligibility for all categories of medically needy medical assistance, with the exception of individuals eligible for nursing facility care, whose eligibility for medically needy medical assistance shall be determined pursuant to He-W 658.05.

 

(b)  The maximum monthly PIL shall be as listed in Table 600.11, protected income levels, below:

 

Table 600.11, Protected Income Levels

 

Assistance Group Size

Protected Income Levels

1

$591

2

$675

3

$683

4

$691

5

$698

6

$779

7

$842

8

$935

9

$987

10

$1064

11

$1151

12

$1223

For each additional person over 12, $67 shall be added.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91; ss by #5530, eff 12-16-92; ss by #6865, eff 10-3-98; amd by #6952, eff 3-1-99; ss by #7226, eff 4-1-00; amd by #7451, eff 2-17-01; amd by #7622, INTERIM, eff 1-9-02 EXPIRED: 7-8-02; amd by #7693, eff 5-25-02; amd by #7803, INTERIM, eff 1-1-03, EXPIRED: 6-30-03; amd by #7876, eff 4-23-03; amd by #8015, eff 1-1-04, EXPIRED: 6-29-04; amd by #8092, eff 5-28-04; amd by #8252, eff 1-8-05; amd by #8433, eff 9-21-05 ss by #9111, INTERIM, eff 3-24-08, EXPIRES: 9-20-08; ss by #9208, eff 7-19-08; ss by #11169, eff 8-26-16 (See Revision Note #1 at Part heading for He-W 858)

 

          He-W 858.05  Eligibility for Adult Category Medical Assistance Nursing Care.

 

          (a)  The nursing facility cap shall be 300% of the maximum SSI benefit for an eligible individual as determined in accordance with 20 CFR 416.410, adjusted by cost-of-living increases pursuant to 20 CFR 416.405.

 

          (b)  The individual shall be income eligible for nursing facility care as categorically needy when the individual’s monthly gross income, as defined in He-W 601.04(o), is less than or equal to the nursing facility cap specified in (a) above.

 

          (c)  The individual shall be income eligible for nursing facility care as medically needy when:

 

(1)  The individual's monthly gross income, as defined in He-W 601.04(o), exceeds the nursing facility cap specified in (a) above; and

 

(2)  The individual’s net income, as defined in He-W 601.05(v), is less than or equal to the monthly medicaid nursing facility rate, as defined in He-E 806.01(aa).

 

(d)  When determining resource eligibility for nursing facility care as categorically needy, $1,000 of the individual’s resources shall be disregarded.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91; ss by #5316, eff 1-27-92; ss by #5561, eff 1-22-93; ss by #5790, eff 2-22-94; ss by #5966, eff 1-27-95; amd by #6969, eff 4-1-99; ss by #7824, eff 2-8-03; ss by #9289, eff 10-3-08; ss by #12050, eff 11-19-16 (See Revision Note #2 at Part heading for He-W 858)

 

He-W 858.06  Eligibility for Adult Category Medical Assistance for Home and Community-Based Care Choices for Independence (HCBC-CFI), Home and Community-Based Care for the Developmentally Disabled (HCBC-DD), Home and Community-Based Care for Individuals with an Acquired Brain Disorder (HCBC-ABD), and Home and Community-Based Care for In-Home Supports (HCBC-IHS).

 

(a)  The individual shall be income eligible for HCBC-CFI, HCBC-DD, HCBC-ABD, or HCBC-IHS services as medically needy when:

 

(1)  The individuals’ monthly gross income, as defined in He-W 601.04(o), exceeds the nursing facility cap specified in He-W 858.05(a); and

 

(2)  The individual’s net income, as defined in He-W 601.05(v), is equal to or less than the PIL, as specified in He-W 858.04(b).

 

(b)  If the individual’s net income in (a)(2) above exceeds the protected income level (PIL), medically needy income eligibility shall be determined in accordance with He-W 878.01.

 

(c)  When determining resource eligibility for individuals described in 42 CFR 435.217(a) at the categorically needy level, $1,000 of the individual’s resources shall be disregarded.

 

Source.  #7223, eff 3-30-00; ss by #9111, INTERIM, eff 3-24-08, EXPIRED: 9-20-08

 

New.  #9289, eff 10-3-08; rpld by #9499, EMERGENCY RULE, eff 6-30-09; ss by #9289, eff 10-3-08, reinstated by REPEAL OF EMERGENCY RULE, #9524, eff 7-31-09; ss by #12050, eff 11-19-16 (See Revision Note #2 at Part heading for He-W 858)

 

PARTS He-W 859 through He-W 863 & PARTS He-W 865 through He-W 875  RESERVED

 

PART He-W 864  MEDICALLY NEEDY MEDICAL ASSISTANCE

 

          He-W 864.01  RESERVED

 

          He-W 864.02  Parents and Other Caretaker Relatives Medically Needy Medical Assistance.

 

          (a)  The following individuals, who are residing in the same housing unit, shall be included in the budgetary unit, as defined in He-W 601.02(e), when determining an individual’s eligibility for parents and other caretaker relatives medically needy medical assistance:

 

(1)  All children who meet the age criteria for dependent child, who are siblings, half siblings, and step siblings; and

 

(2)  All of the children’s natural parents, stepparents, and caretaker relatives, as defined in He-W 601.02(h), who are receiving assistance.

 

          (b)  For pregnant women, in addition to the individuals listed in (a), the following shall be included in the budgetary unit:

 

(1)  Unborn child(ren); and

 

(2)  The father of the unborn child(ren) if he is married to and residing with the pregnant woman.

 

          (c)  Individuals listed in (a) or (b) above who are recipients of federal supplemental security income (SSI) or adult category financial assistance shall not be included in the budgetary unit except when their own eligibility is being determined.

 

          (d)  The countable net income of non-SSI spouses or parents shall be treated as follows in determining an individual’s eligibility:

 

(1)  The countable net income shall be prorated according to the total number of individuals in the budgetary unit; and

 

(2)  The prorated amount shall then be multiplied by the total number of individuals in the budgetary unit to determine each individual’s eligibility.

 

Source.  #12773, eff 5-7-19 (formerly He-W 664.02)

 

PART He-W 876  NURSING FACILITIES

 

Revision Note:

 

          Document #10895, effective 7-22-15, readopted with amendments He-W 676.01 titled “Financial Eligibility for Nursing Facilities” and renumbered the rule as He-W 876.01.  The source note information for He-W 876.01 prior to Document #10895 includes the documents filed under He-W 676.01.

 

          Although He-W 676.01 had last been filed under Document #8903, effective 6-28-07, this rule did not expire on 6-28-15 since it was extended pursuant to RSA 541-A:14-a until replaced by He-W 876.01 in Document #10895, effective 7-22-15.

 

He-W 876.01  Financial Eligibility for Nursing Facilities.

 

(a)  The department shall provide medical assistance for all the dates for which payment is requested when the following criteria have been met:

 

(1)  The individual has been determined eligible for categorically or medically needy medical assistance;

 

(2)  The individual has been determined eligible for a medical service for all dates for which medical payment is requested;

 

(3)  The individual has satisfied all procedural requirements; and

 

(4)  The individual has been physically placed at the proper level of care.

 

(b)  Each individual applying for or in nursing facility care shall be treated as an assistance group of one.

 

(c)  If the individual's net income, as defined in He-W 601.05(v), is greater than the rate of the nursing facility, the individual shall be eligible for in and out medically needy medical assistance, as defined in He-W 601.05(b), and the cost of the nursing facility care shall be an allowable expense for spending down to the protected income level, as defined in He-W 601.06(s).

 

(d)  Nursing care payments shall be made only on behalf of individuals in licensed, certified nursing facilities.

 

(e)  Individuals in licensed but uncertified nursing facilities shall be considered to be residing in an independent living arrangement.

 

(f)  The nursing facility rate used in determining eligibility shall remain in effect until the next eligibility determination.

 

(g)  The veteran’s affairs aid and attendance allowance shall be used in full to offset the cost of nursing facility care.

 

(h)  A deduction for the cost of health insurance shall be allowed regardless of whether the expense is mandatory or voluntary.

 

(i)  Whenever health insurance premiums are due more frequently than monthly, the cost shall be converted to a monthly amount in accordance with He-W 652.05.

 

(j)  Whenever health insurance premiums are due less frequently than monthly, the cost shall be averaged over the period it is intended to cover in order to obtain a monthly amount.

 

Source.  (See Revision Note #1 at Chapter heading for He-W 600) #5171, eff 6-26-91; ss by #5565, eff 2-8-93; ss by #6955, eff 3-3-99; ss by #8783, INTERIM, eff 12-30-06, EXPIRES: 6-28-07; ss by #8903, eff 6-28-07; ss by #10895, eff 7-22-15 (See Revision Note at Part heading for He-W 876)

 

PART He-W 877  RESERVED

 

PART He-W 878  IN AND OUT MEDICALLY NEEDY MEDICAL ASSISTANCE

 

Revision Note:

 

          Document #10743, effective 12-12-14, readopted with amendments He-W 678.01 titled “In and Out Medically Needy Medical Assistance”, the only rule in Part He-W 678 similarly titled “In and Out Medically Needy Medical Assistance”, and renumbered the rule as He-W 878.01 in a new Part He-W 878, both titled “In and Out Medically Needy Medical Assistance”.  The source note information for He-W 878.01 prior to Document #10743 includes the documents filed under He-W 678.01.

 

Although He-W 678.01 had last been filed under Document #8684, effective 7-21-06, this rule did not expire on 7-21-14 since it was extended pursuant to RSA 541-A:14-a until replaced by He-W 878.01 in Document #10743, effective 12-12-14.

 

          He-W 878.01  In and Out Medically Needy Medical Assistance.

 

          (a)  The department shall provide in and out medically needy medical assistance in accordance with 42 CFR 435.301 to individuals:

 

(1)  Who meet all categorical, technical, and resource requirements for medically needy medical assistance;

(2)  Whose income exceeds the protected income level for medically needy medical assistance; and

 

(3)  Whose incurred medical expenses and obligated prior medical debts, including non-covered medical services incurred in an eligible month, which have not been used to offset a prior spenddown, are at least equal to the difference between their income and the protected income level for medically needy medical assistance.

 

          (b)  The department shall recognize the following incurred medical expenses, and currently unpaid, obligated prior medical debts toward the in and out spenddown:

 

(1)  Medical insurance premiums, deductibles or co-insurance charges;

 

(2)  Necessary medical or remedial care that would be covered by medical assistance including when allowable incurred amounts exceed service limits described in He-W 530.03; and

 

(3)  Necessary medical or remedial care that is recognized by state law but not covered by medical assistance described in He-W 530.06(a).

 

          (c)  Incurred current medical expenses and obligated prior medical debts of individuals of a family, as defined in He-W 601.04(c), or family members, as defined in He-W 601.04(f), who reside in the same living unit as the client or for whom the client is liable, shall be used to satisfy the spenddown amount.

 

          (d)  Prior medical debts shall not be prioritized or required to be used in sequential order and shall be prorated at the client's option over several months if the total amount of the debt exceeds the spenddown amount.

 

          (e)  The department shall apply incurred, unpaid medical expenses and currently obligated medical debts toward the spenddown in the following order:

 

(1)  Unpaid prior medical debts and uncovered medical expenses shall be applied on the first day of the month of the in and out period;

 

(2)  Medical insurance premiums due during the month shall be applied on the first day of the month in which they are due; and

 

(3)  Current medical expenses which are or would be covered by medical assistance shall be applied chronologically after uncovered expenses and may be applied to the following month if they remain unpaid on the first day of the following month and have not already been applied toward a spenddown.

 

          (f)  A medical expense or prorated expense described in (d) above shall be used only once to offset the spenddown.

 

          (g)  The client may choose either a one or 6 month spenddown period when the department determines eligibility for in and out medically needy medical assistance, subject to the following provisions:

 

(1)  An application for in and out medically needy medical assistance shall be valid only for a maximum of 6 consecutive months;

 

(2)  The client shall be given the spenddown amounts for both a one and 6 month spenddown period on their notice of decision;

 

(3)  The client shall not be required to choose either a one or 6 month spenddown until they submit verification of medical expenses to the department and the case meets all eligibility criteria; and

 

(4)  Once the client has elected a one month spenddown period and the case has been opened, they shall not have a 6 month spenddown period unless they reapply for assistance.

 

          (h)  When the client has chosen a one month spenddown period, the amount by which monthly income exceeds the protected income level as defined in He-W 601.06(s) shall be the client's spenddown amount, and the spenddown amount shall be computed separately for each month.

 

          (i)  When the client has chosen a 6 month spenddown period, the spenddown amount shall be equal to 6 times the difference between monthly income and the protected income level.

 

          (j)  Reported or known changes in case circumstances such as, but not limited to, changes in income, household composition, and increases in the protected income level shall affect the one month spenddown amount as follows:

 

(1)  Before a case is opened for a one month period, changes in case circumstances which affect the spenddown amount shall be used to determine eligibility; and

 

(2)  Once a case is opened for a one month period, changes in case circumstances shall not affect the spenddown amount.

 

          (k)  Reported or known changes in case circumstances, such as but not limited to changes in income, household composition, and increases in the protected income level which affect the 6 month spenddown amount shall be used to determine eligibility as follows:

 

(1)  Before a case is opened for a 6 month period, all known changes affecting that 6 month period shall be taken into account prior to opening, and the department shall calculate the changes for the affected months and establish a new spenddown for the 6 months;

 

(2)  Once a case has been opened for a 6 month spenddown period and has a change that would increase the spenddown amount, the department shall take the change into account and take action to review eligibility by computing a new spenddown amount and, if the case is ineligible, terminate in and out medically needy medical assistance; and

 

(3)  Once a case has been opened for a 6 month spenddown period and has a change that would decrease the spenddown amount, the department shall determine if the decrease affects the original date of eligibility.

 

          (l)  Eligibility for in and out medically needy medical assistance shall begin on the day of the month in which incurred medical costs equal or exceed the amount of the spenddown.

 

          (m)  The client shall notify the department in person, in writing, or by telephone when he or she has incurred medical costs which equal or exceed the amount of the spenddown.

 

Source.  (See Revision Note #1 at Chapter heading for He-W 600) #5171, eff 6-26-91; ss by #5508, eff 12-1-92; ss by #6865, eff 10-3-98; ss by #8684, eff 7-21-06; ss by #10743, eff 12-12-14 (See Revision Note at Part heading for He-W 878)

 

PARTS He-W 879 –through He-W 881  RESERVED

 

PART He-W 882  Termination of Medical Assistance

 

Revision Note:

 

          Document #11169, effective 8-22-16, readopted with amendments He-W 682.04 titled “Four Month Extended Medical Assistance Due to Increased Child Support” and renumbered the rule as He-W 882.04 titled “Four Month Extended Medical Assistance Due to New or Increased Spousal Support.”  Document #11169 also readopted with amendments He-W 682.05 titled “Twelve Month Extended Medical Assistance” and renumbered the rule as He-W 882.05.  The source note information for He-W 882.04 prior to Document #11169 includes the documents filed under He-W 682.04, and the source note information for He-W 882.05 prior to Document #11169 includes the documents filed under He-W 682.05.

 

          Although He-W 682.04 and He-W 682.05 had last been filed under Document #9207, effective 7-19-08, these rules did not expire on 7-19-16 since they were extended pursuant to RSA 541-A:14-a until replaced by He-W 882.04 and He-W 882.05, respectively, in Document #11169, effective 8-26-16.

 

          He-W 882-01 through He-W 882.03 – RESERVED

 

          He-W 882.04  Four Month Extended Medical Assistance Due to New or Increased Spousal Support.  Pursuant to 42 CFR 435.115, as amended, and 42 USC 1396u-1(c)(1), medical assistance shall be extended for 4 additional months when the primary reason for the termination of categorically needy medical assistance is increased income which was caused in whole or in part by new or increased spousal support income.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91; ss by #6531, INTERIM, eff 6-27-97, EXPIRES: 10-25-97; ss by #6614, eff 10-24-97; ss by #7328, eff 8-1-00; ss by #9207, eff 7-19-08; ss by #11169, eff 8-26-16 (See Revision Note at Part heading for He-W 882)

 

He-W 882.05  Twelve Month Extended Medical Assistance.

 

(a)  Assistance groups receiving a category of financial assistance to needy families (FANF) financial assistance, as defined in He-W 601.04(g), shall be eligible to receive up to 12 months of extended medical assistance when termination of FANF financial assistance was due solely to:

 

(1)  Increased hours of employment; or

 

(2)  Increased income from employment.

 

(b)  If one of the conditions in (a)(1)-(2) above are met, the requirement that the household has received financial assistance in at least 3 of the last 6 months shall not apply, pursuant to 42 USC 1396r-6(a)(1)(B).

 

(c)  Good cause for failure to return a complete quarterly report timely, as required by 42 USC 1396r-6(b)(2)(B), shall be limited to the following circumstances:

 

(1)  Mail delay;

 

(2)  Illness of the parent or caretaker relative, or other family member; or

 

(3)  Emergencies such as floods, fires, loss of shelter, or similar events which prevent the family from returning the quarterly report on time.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91; amd by #6446, eff 2-1-97; amd by #6531, INTERIM, eff 6-27-97, EXPIRES: 10-25-97; amd by #6614, eff 10-24-97; ss by #7328, eff 8-1-00; ss by #9207, eff 7-19-08; ss by #11169, eff 8-26-16 (See Revision Note at Part heading for He-W 882)

 

PART He-W 883  RESERVED

 

            He-W 884.01  Redeterminations - General.

 

            (a)  A redetermination of eligibility shall be required under the following conditions:

 

(1)  At regularly scheduled intervals as prescribed by federal regulations;

 

(2)  Prior to the expiration of extended medical assistance coverage periods, if the individual requests a redetermination of eligibility for benefits;

 

(3)  When requested by the individual;

 

(4)  When the department of health and human services (DHHS) discovers conflicting information regarding eligibility factors; or

 

(5)  When a change in case circumstances affects other eligibility factors.

 

Source.  #13524, eff 1-24-33

 

            He-W 884.02  Regularly Scheduled Redeterminations.

 

            (a)  For modified adjusted gross income (MAGI) based medical assistance, redeterminations shall be scheduled no more than once every 12 months.

 

            (b)  For non-MAGI based medical assistance, redeterminations shall be scheduled at least every 12 months.

 

Source.  #13524, eff 1-24-33

 

PARTS He-W 885 through He-W 894  RESERVED

 

PART He-W 895  UNDUE HARDSHIP

 

Revision Note:

 

          Document #11170, effective 8-22-16, readopted with amendments Part He-W 695 titled “Undue Hardship”, which contained He-W 695.01 through He-W 695.08, and renumbered He-W 695 as He-W 895, containing He-W 895.01 through He-W 895.08.  The source note information for He-W 895.01 through He-W 895.08 prior to Document #11170 includes the documents filed under He-W 695.01 through He-W 695.08, respectively.

 

          Although He-W 695 had last been filed under Document #9225, effective 8-1-08, the rules in He-W 695 did not expire on 8-1-16 since they were extended pursuant to RSA 541-A:14-a until replaced by the rules in He-W 895 in Document #11170, effective 8-26-16.

 

          He-W 895.01  Purpose.  The purpose of these rules is to establish criteria for:

 

          (a)  The determination of undue hardship pursuant to 42 USC 1396p(b)(3); and

 

          (b)  The waiver of the state's claim for recovery of medical assistance granted against a deceased Medicaid recipient's estate where estate recovery would result in an undue hardship.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.02  Definitions.

 

          (a)  “Applicant” means the individual who submits the written request that the department waive its right to recover for medical assistance provided to the deceased Medicaid recipient.

 

          (b)  "Cost effective" means the amount of public assistance recovered exceeds the total cost to the department of pursuing the recovery by $500.00 or more.

 

          (c)  "Department" means the department of health and human services.

 

          (d)  "Estate" means all assets and liabilities of a Medicaid recipient subject to the jurisdiction of the probate court, including but not limited to all property, real or personal, in a revocable trust as contemplated by RSA 167:14-a, V and property held by the recipient during his or her lifetime in either joint tenancy, tenancy in common, or life estate as contemplated at RSA 167:14-a, VI.

 

          (e)  "Heir" means those persons, including the surviving spouse, who might be entitled to some or all of the estate of the Medicaid recipient under the statutes of succession.

 

          (f)  "Income producing property" means real property, either residential, commercial or industrial upon which money is made, such as rental property.

 

          (g)  "Medicaid recipient" means an individual who receives or received Medicaid benefits.

 

          (h)  “Medical institution” means any nursing facility as defined at 42 USC §1396r(a), long term care facility for the mentally retarded as defined at 42 USC §1396d(d), or medical institution as defined at 42 CFR §435.1010.

 

          (i)  “Medical professional” means any doctor, physician’s assistant, nurse, nurse practitioner, licensed nursing assistant or certified nursing assistant who regularly provided treatment to the deceased Medicaid recipient prior to the deceased Medicaid recipient’s admission to the medical institution.

 

          (j)  "Primary residence" means the applicant’s or heir's domicile.

 

          (k)  "Probate court" means the court having jurisdiction over the administration of estates as provided by RSA 547:3.

 

          (l)  “Uncompensated care” means care provided to the deceased Medicaid recipient gratuitously, without compensation from the department or any other person, organization, or agency and for which the applicant has not filed a claim against the estate for reimbursement under any theory of law or equity.

 

          (m)  "Undue hardship" for purposes of He-W 695, means circumstances described in these rules that would make application of the department's right to recovery unfair and which, if verified as provided in these rules, would result in the department's waiving its right to recover for medical assistance correctly paid on behalf of the deceased Medicaid recipient.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.03  Waiver of Recovery.

 

          (a)  The administrator or executor of the estate, the surviving joint tenant or remainderman of a life estate shall receive written notice of the right to request a waiver of recovery under these rules, including criteria for determining undue hardship and the procedure for requesting such a waiver concurrent with the notification of the department’s claim.

 

          (b)  Recovery of medical assistance pursuant to RSA 167:14 shall be waived if recovery will result in undue hardship to the heir as determined under He-W 895.04 or if the department determines that it is not cost effective to recover the assistance paid.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.04  Criteria for Determination of Undue Hardship.  The department shall waive recovery on the basis of undue hardship as provided in (a), (b), (c), (d), (e) or (f) below:

 

          (a)  Where the estate includes real property on which a business or farm is located and:

 

(1)  The business or farm has been in operation at the primary residence of the heir for at least 12 months preceding the death of the decedent;

 

(2)  The business or farm produces more than 50% of the heir's livelihood; and

 

(3)  The recovery of the claim would directly result in the loss of the livelihood of the heir;

 

          (b)  Where the estate includes income-producing property and:

 

(1)  The heir has used his/her own personal resources for the past 12 months to maintain the income-producing property;

 

(2)  The property produces more than 50% of the heir's livelihood; and

 

(3)  The recovery of the claim would directly result in the loss of the livelihood of the heir;

 

          (c)  Where the estate includes only personal property and recovery by the department would directly result in the heir becoming eligible for public assistance;

 

          (d)  Where the estate includes the home of the Medicaid recipient upon which the department placed a lien or upon which the department had authority to place a lien but didn’t due to insufficient time, and:

 

(1)  The applicant is an adult child of the deceased Medicaid recipient;

 

(2)  The applicant is the grandchild of a deceased Medicaid recipient who died on or after January 1, 2008 and who can establish that the deceased Medicaid recipient had guardianship over the applicant while the applicant was a minor or that the deceased Medicaid recipient served as in-loco parentis to the applicant while he or she was a minor;

 

(3)  The applicant resided in the home of the deceased Medicaid recipient for a period of at least 2 years immediately before the date of the deceased Medicaid recipient's admission to the medical institution;

 

(4)  The applicant establishes that he or she provided uncompensated care daily to the deceased Medicaid recipient for at least 2 years immediately before the date of the deceased Medicaid recipient’s admission to the medical institution which permitted the deceased Medicaid recipient to reside at home rather than in a medical institution, including but not limited to any or all of the following activities:

 

a.  Bathing;

 

b.  Dressing;

 

c.  Administering medication;

 

d.  Shopping;

 

e.  Cooking;

 

f.  Feeding;

 

g.  House cleaning;

 

h.  Money management;

 

i.  Driving; or

 

j.  Other care specific to the condition of the deceased Medicaid recipient; and

 

(5)  The applicant is lawfully residing in the home of the deceased Medicaid recipient and has lawfully resided in such home on a continuous basis since the date of the deceased Medicaid recipient's admission to the medical institution;

 

          (e)  Where the estate includes the home of the Medicaid recipient, and:

 

(1)  The applicant is a sibling of the deceased Medicaid recipient;

 

(2)  The applicant resided in the home of the deceased Medicaid recipient for a period of at least one year immediately before the date of the deceased Medicaid recipient's admission to the medical institution; and

 

(3)  The applicant is lawfully residing in the home of the deceased Medicaid recipient and has lawfully resided in such home on a continuous basis since the date of the deceased Medicaid recipient's admission to the medical institution; or

 

          (f)  Where the estate includes the home of the Medicaid recipient which she or he held either in life estate or in joint tenancy, and:

 

(1)  The applicant can demonstrate that he or she is either the remainderman under the life estate or the surviving joint tenant; and

 

(2)  The applicant can demonstrate that he or she paid value for the remainder interest or joint interest either when the interest was created or to cure a transfer of asset penalty contemplated at He-W 820.01(s)(3).

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.05  Request for Undue Hardship.

 

          (a)  A request for an undue hardship waiver shall be in writing and include the following information:

 

(1)  The deceased Medicaid recipient's name;

 

(2)  The deceased Medicaid recipient's last street address;

 

(3)  The applicant’s name;

 

(4)  The applicant’s relationship to the deceased Medicaid recipient; and

 

(5)  The reason(s) for the undue hardship waiver request as described in He-W 895.04.

 

          (b)  Relevant documentation shall be attached to support the undue hardship waiver request including, but not limited to, the following:

 

(1)  Mortgage note;

 

(2)  Real property deed;

 

(3)  IRS forms, including business, personal or farm deduction forms;

 

(4)  Proof of residency such as a copy of the heir's driver's license or W-2;

 

(5)  Canceled checks relating to the income producing property or business;

 

(6)  City or town tax assessor bills;

 

(7)  A copy of the deceased Medicaid recipients' death certificate;

 

(8)  Estate paperwork filed with probate court;

 

(9)  An affidavit from the applicant describing the kind and quality of care provided the deceased Medicaid recipient including dates the care was provided, if applicable; and

 

(10)  Affidavits from at least 2 medical professionals who cared for the deceased Medicaid recipient prior to admission to the medical institution stating that the applicant provided the kind and quality of care necessary to maintain the Medicaid recipient at home rather than in a medical institution for at least 2 years immediately before the Medicaid recipient’s admission to the medical institution.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.06  Undue Hardship Request Review.

 

          (a)  A request for a hardship waiver shall be filed with the department within 30 calendar days from the Medicaid recipient's death or within 30 calendar days from the date of the filing of the department's claim with the probate court, whichever is later.

 

          (b)  The request shall contain a written statement of the circumstances constituting the hardship and supporting documentation as described in He-W 895.05.

 

          (c)  Determinations of the existence of undue hardship shall be made within 90 calendar days from the date of the hardship waiver request.

 

          (d)  A written notice of decision shall be sent to the person making the request.

 

          (e)  All denial notices shall include a statement informing the applicant that he/she may appeal the department's decision and instructions for how to request an administrative appeal.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.07  Reduction from Claim Against Non-Probate Assets.

 

          (a)  Surviving joint tenants or remainderman of life estates shall be eligible for a dollar-for-dollar reduction in the amount of the department’s claim for medical assistance correctly paid on behalf of a deceased Medicaid recipient when he or she can demonstrate that he or she advanced their personal funds to provide for a shortfall in the deceased Medicaid recipient’s expenses reasonable and necessary for burial as contemplated at RSA 554:19, I(b).

 

          (b)  Satisfactory documentation of personal funds advanced shall be cancelled checks and billing statements from the entity providing the disposition services such as a funeral home, crematory or monument company.

 

          (c)  No reduction shall be granted for expenses that are not necessary for burial as contemplated at RSA 554:19, II including but not limited to flowers, music, post-prandial meals, travel expenses to or from funeral services, telephone or postage expenses.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

          He-W 895.08  Administrative Hearings.

 

          (a)  A decision pursuant to He-W 895.06 shall be final unless within 30 calendar days of the date of the decision, a request is submitted for an administrative appeal pursuant to He-C 200.

 

          (b)  If the department's administrative appeal process finds in favor of the applicant, then the department shall withdraw its claim for recovery from probate court.

 

Source.  (See Revision Note #1 at Chapter Heading He-W 600) #5171, eff 6-26-91, EXPIRED: 6-26-97

 

New.  #7311, eff 6-22-00; ss by #7667, eff 3-27-02; ss by #9225, eff 8-1-08; ss by #11170, eff 8-26-16 (See Revision Note at Part heading for He-W 895)

 

PARTS He-W 896 through He-W 898  RESERVED

 

PART He-W 899  SPECIAL PAYMENT SITUATIONS

 

          He-W 899.02  Post Office Boxes and General Delivery Mailing Addresses.

 

          (a)  Notices, letters, or any other correspondence from the department relative to programs administered by the department shall be mailed to a post office box or general delivery address only when the client lives in an area where home delivery of mail is not available, or the area is subject to extensive mail pilferage.

 

          (b)  The client shall provide verification in writing of the reason for the request to have mail sent to an address other than the residence address.

 

          (c)  If use of a post office box or general delivery mailing address is not verified, the department mail described in (a) above shall be mailed to the residence address.

 

Source.  #10743, eff 12-12-14

 


APPENDIX A:  Incorporation by Reference Information

 

Rule

Title

Publisher; How to Obtain; and Cost

He-W 837.04(a)(1)

ASAM Criteria:  Treatment Criteria for Substance-Related, Addictive, and Co-Occurring Conditions, 3rd edition (2013)

Publisher:  American Society of Addiction Medicine (ASAM).

The ASAM Criteria (2013) can be purchased online through the ASAM website at: http://www.asamcriteria.org/.

Cost = $95 (non-members) or $85 (members). Discounts are available for large purchases.




 

APPENDIX B

 

Rule

Specific State Statute the Rule Implements

He-W 802.03

RSA 161:4-a, IV; RSA 167:3-c, I; RSA 167:4; RSA 167:8; 42 CFR 435.907

He-W 803.01

42 CFR 435.908(b), 42 CFR 435.923

He-W 803.02

RSA 167:17-b, RSA 641:3

He-W 803.03

RSA 167:17, 42 CFR 435.916(c)

He-W 804.04

RSA 167:3-c,I; RSA 167:83,II(b); 45 CFR 206.10(a)(4)

He-W 804.05

RSA 167:3-c,I; RSA 167:31; RSA 167: 32; RSA 167:83,II(b);

45 CFR 206.10(a)(4); 42 CFR 431.300-42 CFR 431.307

He-W 806.18

42 CFR 435.1009, 42 CFR 435.1010

He-W 806.37

RSA 167:3-c,I; 42 CFR 435.608; 42 CFR 435.914

He-W 806.55

RSA 167:3-b; RSA 167:3-c,I; RSA 167:79,V(b); RSA 167:80;

He-W 806.60

RSA 161:4-a,II; RSA161:4-a,X(g); RSA 167:3-c,I; RSA 167:7,IV;

RSA 167:17,III; RSA 167:17-b,I(a); RSA 167:17-b,I(d); 42 CFR 435.601(b)

He-W 806.68

RSA 167:4,I(a); 42 CFR 435.914

He-W 806.69

RSA 167:6,VI; 20 CFR 416.905; 20 CFR 416.976; 20 CFR 416.1112(c)(6); 42 CFR 435.914; 42 USC 1382c

He-W 806.74

RSA 167:4,I(a); 42 CFR 435.733(c)(4)(ii); 42 CFR 435.832(c)(4)(ii)

He-W 806.78

RSA 167:4; RSA 167:7, IV; 42 CFR 435.601(b), 42 CFR 435.914

He-W 806.89

RSA 161:4-a,X; RSA 167:3-c,I; 42 CFR 435.4; 42 CFR 435.300; 42 CFR 435.301; 42 CFR 435.330; 42 CFR 435.831; 42 USC 1396a(a)(10); 42 USC 1396d(a)

He-W 806.92

RSA 161:4-a, IX; RSA 167:3-c, I; 42 CFR 435.908

He-W 816.02

RSA 167:3-c, I; 8 USC 1641(b); 42 USC 602(a)(1)(B)(ii); 42 CFR 435.406

He-W 820.01

RSA 126-A:4-b,(a); RSA 161:4-a, II; RSA 167:3-c, I; RSA 167:4, I(b), III-a, & IV; 42 USC 1396p(c); 42 USC 1382a

He-W 821.01

RSA 126-A:4-b,(a); RSA 167:3-c, I; RSA 167:4, III-a & IV; 42 USC 1396p(c)(2)(D)

He-W 821.02

RSA 126-A:4-b,(a); RSA 167:3-c, I; RSA 167:4, III-a & IV; 42 USC 1396p(f)

He-W 821.03

RSA 126-A:4-b,(a); RSA 126-A:5, VIII; 42 USC 1396p(c)(2)(D)

He-W 824.01

42 CFR 435.1009, 42 CFR 435.1010

He-W 830.01

RSA 169-C:3,XIV; RSA 167:6; RSA 167:78; RSA 167:79,II & V(b)

He-W 837.01

RSA 126-AA; 42 U.S.C. 12101 et seq.; Pub.  L. No. 93-112; Pub.  L. 111-148; 42 CFR 435.916

He-W 837.02

42 CFR 435.603(a)-(h)

He-W 837.03

RSA 126-AA

He-W 837.04

RSA 126-AA; RSA 167:82,II(g); 42 CFR 435.4; 42 CFR 440.315(f)

He-W 837.05

RSA 126-AA; RSA 167:3-i; RSA 167:6, IV-VI; RSA 167:3-e; RSA 167:3-f; 42 U.S.C.1396a(a)(10)(A)(ii)(XV); 42 CFR 435.4; 42 CFR 435.121; 42 U.S.C. 1396a(e)-(f); 42 U.S.C. 1396n; 42 U.S.C. Chapter 7; 42 U.S.C. 1381 et seq.

He-W 837.06

RSA 126-AA

He-W 837.07

RSA 126-AA; RSA 641:3; RSA 167:82,II(g)

He-W 837.08

RSA 126-AA; 45 CFR 475

He-W 837.09

RSA 126-AA; 45 CFR 400.75

He-W 837.10

RSA 126-AA; 42 U.S.C. 12101 et seq.

He-W 837.11

RSA 126-AA

He-W 837.12

RSA 126-AA; 24 CFR 5.2005; 24 CFR 5.2009

He-W 837.13

RSA 126-AA

He-W 837.14

RSA 126-AA; 24 CFR 5.2005; 24 CFR 5.2009

He-W 837.15

RSA 126-AA

He-W 837.16

RSA 126-AA; 42 CFR 435.916(f)

He-W 837.17

RSA 126-AA

He-W 837.18

RSA 126-AA

He-W 841.03

RSA 167:3-I; RSA 167:3-c,XII;RSA 167:6,IX; 42 USC 1396a(a)(10)(A)(ii)(XV) [Section 1902(a)(10)(A)(ii)(XV) of the Social Security Act]

He-W 844.01

RSA 161:4-a, IX; RSA 167:3-c, I;

He-W 848.03

RSA 167:3-c, II-b; RSA 167:7, I-a; RSA 167:27-c; 42 USC 1382g

He-W 852.06

RSA 161:4-a, IX; RSA 167:3-c, I

He-W 852.07

RSA 167:3-c, I; RSA 161:4-a, IX; 42 CFR 435.608

He-W 854.02

RSA 167: 3-c, IX, RSA 167:4, I(a); RSA 167:6, VII; Section 1902(f) of the Social Security Act (SSA) [42 USC 1396a(f)]; 42 CFR 435.401(c)(2); 42 CFR 435.601(b);

He-W 854.15

RSA 167:3-c, IX, RSA 167:4, I; 20 CFR 416.976, 20 CFR 416.1112

He-W 854.16

RSA 167:4, I(a)

He-W 854.17

RSA 167:27-a,, 42 CFR 435.733, 42 CFR 435.832, 38 USC 5503, Section 1924(d) of the SSA [42 USC 1396r-5(d)]

He-W 854.18

RSA 167:3-c, IX ; RSA 167:4, I(a); Section 1902(a) of the SSA [42 USC 1396a(a)(17)(B),(C)]; 20 CFR 416.1112(c); 42 CFR 435.601(b)

He-W 854.20

RSA 167:4, I(a)

He-W 856.01

RSA 167:4, 42 CFR 435.725(c)(2), 42 CFR 435.832(c)(2), 42 CFR 435.840, 42 USC 1396a(q), Section 1924(c)(1) & (d)-(g) of the SSA [42 USC 1396r-5(c)(1) & (d)-(g)]

He-W 856.02

RSA 161:4-a, III; 42 USC 604(h); 45 CFR 263.20-23; 45 CFR 260.31(b)(5)

He-W 856.03

RSA 167:3-c,I; RSA 167:4-a; RSA 167:7,IV; 42 USC 1396p(c)(3); 42 CFR 435.845

He-W 856.04

RSA 167:3-c,I; RSA 167:4; RSA 167:17; RSA 167:81; RSA 167:83 II(m)

45 CFR 233.20(a)(3); Section 1612(a)(2)(G) of the Social Security Act (SSA)

[42 USC 1382a(a)(2)(G)]; Section 1613 of the SSA [42 USC 1382b]

Section 1902(a)(10)(A)(ii)(XIII) of the SSA [42 USC 1396a(a)(10(A)(ii)(XIII)]

Section 1917(c)(1)(H)-(I) of the SSA [42 USC 1396p(c)(1)(H)-(I)]

Section 1917(d) of the (SSA) [42 USC 1396p(d)]

He-W 856.05

RSA 161:4-a, II; RSA 167:3-c, I; 42 CFR 435.210

He-W 856.06

RSA 167: 4, IV(d); 42 CFR 435.10; 42 CFR 435.210; 42 CFR 435.601; 42 CFR 435.840; 42 CFR 435.843, 42 CFR 435.845

He-W 858.04

42 USC 1396b(f)(1)(A)-(C); 42 USC 1396u–1(b)

He-W 858.05

RSA 151-E:3; RSA 167:4, I(a); 20 CFR 416.405; 20 CFR 416.410; 42 CFR 435.211; 42 CFR 435.236; 42 CFR 435.622

He-W 858.06

RSA 151-E:3; RSA 167:4, I(a), 42 CFR 435.217(a); 42 CFR 435.622; 42 CFR 435.831(b)-(c); 42 CFR 435.1005

He-W 864.02

RSA 167:6, VII; RSA 167:79, II; 42 CFR 435.310; 42 CFR 435.603(a)(2) & (j)(6); 42 CFR 435.831

He-W 876.01

RSA 167:6,VII; 42 CFR 435.211; 42 CFR 435.622; 42 CFR 435.831;

42 CFR 435.840

He-W 878.01

RSA 161:4-a,X; RSA 167:3-c,I; 42 CFR 435.4; 42 CFR 435.300; 42 CFR 435.301; 42 CFR 435.330; 42 CFR 435.831; 42 USC 1396a(a)(10); 42 USC 1396d(a)

He-W 882.04

42 CFR 435.115(f)-(h); 45 CFR 233.20(a)(15); 42 USC 1396u-1(C)(1)

He-W 882.05

RSA 167:82, VI; 42 USC 1396r-6; 42 USC 1396u-1(c)(2)

He-W 884.01

42 CFR 435.916; RSA 126-A:3,VIII as amended by Chapter 224:43, Laws of NH 2011

He-W 884.02

42 CFR 435.916; RSA 126-A:3,VIII as amended by Chapter 224:43, Laws of NH 2011; RSA 167:3-c,VIII; RSA 167:83,II(d)

He-W 895.01-He-W 895.06

RSA 167:13-16; 42 USC 1396p

He-W 895.07

RSA 167:13-16; RSA 554:19; 42 USC 1396p

He-W 895.08

RSA 167:13-16; 42 USC 1396p

He-W 899.02

RSA 167:3-c,I; 45 CFR 205.32