10A N.C. Admin. Code 23A.0102

Current through Register Vol. 39, No. 12, December 1, 2024

Section 23A .0102 - DEFINITIONS

For purposes of this Chapter, the following definitions apply:

(1) "M-AA" means a program of medical assistance to persons 65 years of age and older, and also means the assistance itself.

(2) "M-AB" means a program of medical assistance to blind persons, and also means the assistance itself.

(3) "M-AD" means a program of medical assistance to disabled persons less than 65 years of age, and also means the assistance itself.

(4) "M-AF" means a program of medical assistance for families and children, and also means the assistance itself.

(5) "M-IC" means a program of medical assistance for infants and children, and also means the assistance itself.

(6) "M-PW" means a program of medical assistance for pregnant women, and also means the assistance itself.

(7) "M-QB" means a program of medical assistance for qualified Medicare beneficiaries described at 42 U.S.C. 1396d(p), and also means the assistance itself.

(8) "AFDC" means a program of assistance for families with dependent children, and also means the assistance itself.

(9) "AFDC-MA" has the same meaning as "M-AF".

(10) "Adequate Notice" means a written notice to inform the client of intended action. The client must receive this notice no later than the effective date of the action.

(11) "Advance Notice" means a written notice to inform the client at least 10 work days prior to terminating assistance, beginning or increasing a deductible, or beginning or increasing patient monthly liability.

(12) "Agency" means the Division of Health Benefits and the county departments of social services, unless separately identified.

(13) "Appeal" means an oral or written request from a client for a hearing to review the action of a county department of social services or the disability decision when the client is dissatisfied with the decision in his case.

(14) "Application" means a written request for assistance on a form prescribed by the state that is signed under penalty of perjury by a client or an individual authorized by the client to be his representative for establishing his eligibility for medical assistance.

(15) "Authorization Period" means the period for which all conditions of eligibility have been established and for which the client is authorized to receive a Medicaid card and benefits.

(16) "Award Letter" means a statement to an individual from a governmental or private agency indicating benefits for which he is eligible.

(17) "BENDEX" means Beneficiary Data Exchange with the Social Security Administration for social security status and amount of benefits.

(18) "Budget Unit" means all persons whose income and needs are considered in the determination of eligibility for Medicaid.

(19) "Certification Period" means the months for which eligibility is being established.

(20) "Client" means any applicant for or recipient of Medicaid, or someone who makes inquiries, is interviewed, or has been otherwise served or someone acting for the client.

(21) "Client Information" or "Client Record" means any information, including information stored in computer data banks or computer files relating to a client that was received in connection with the performance of any function of the agency.

(22) "Collateral" means a person or agency who can substantiate or verify information necessary to establish eligibility.

(23) "Contiguous Property" means real property with boundaries joining the homesite of the client.

(24) "Court Order" means any written order from a judge or a written document from a judicial official that explicitly directs the release of client information.

(25) "Deductible" means the amount that the client or budget unit member must personally spend or incur for medical expenses before he can be authorized to receive a Medicaid card and services that may be billed to the Medicaid program.

(26) "Delegated Representative" means a staff member designated by the director to carry out the responsibilities established by the rules in this Subchapter. Designation is implied when the assigned duties of an employee require access to confidential information.

(27) "Deprivation" means the lack of support or care from one or both parents (including adoptive parents) of a dependent child, as a result of the absence, incapacity, unemployment, or death of either parent.

(28) "Director" means the head of the Division of Health Benefits or the county department of social services.

(29) "Disregard of Earned Income" means the procedure for exempting portions of earned income as a resource when determining the amount of payment.

(30) "Documentary Evidence" means information or records that can be relied on to prove the client's statements of fact.

(31) "Effective Date" means the date on which an action will take effect.

(32) "Equity" means the tax value of a resource less the amount of debts, liens, or other encumbrances.

(33) "Excluded Income" means money received by a member of the budget unit that is not counted in determining eligibility for assistance.

(34) "Foster Care Resource" means any private home or facility licensed to provide full time care to children.

(35) "Fraud" means an act in which a client makes false statements or withholds information willfully and knowingly with the intent to deceive, or both, and as a result obtains assistance for which he is not eligible.

(36) "Full-Time Student" means a student so designated by the school in which he is enrolled.

(37) "Good Cause" includes death, incapacity, hospitalization of the applicant/recipient (a/r), failure to receive written notice, or failure of a representative acting on the a/r's behalf to meet required time frames.

(38) "Grandfathered Status" means Medicaid eligibility based on the individual's status as a blind or disabled client or as an essential spouse of aged, blind, or disabled client in December, 1973.

(39) "Greater Weight of Evidence" means evidence of such quality as to persuade an ordinary and prudent person of the truth or falsity of a statement.

(40) "Guardian" means an individual, corporation, or disinterested public agent appointed by the clerk of superior court to replace an individual's authority to make decisions about his person, family, or property when the individual does not have adequate capacity to make such decisions and has been adjudicated incompetent. A guardian may be a guardian of the person, a guardian of the estate, or a general guardian which is guardian of both the person and the estate.

(41) "HCT (Healthy Children and Teens)" means a program which provides health screenings and treatment for clients from birth through age 20.

(42) "Incapacity" has the same meaning as in the North Carolina State plan approved under Part A of Title IV of the Social Security Act as in effect on July 16, 1996, as is required by 42 U.S.C. 1396u-1.

(43) "Income" means money that is available to members of the budget unit for their needs.

(44) "Income, Earned" means money received as a result of employment.

(45) "Income, Gross" means total income before allowable deductions.

(46) "Income, Net" means income after all allowable deductions.

(47) "Income, Unearned" means money received from any source other than employment.

(48) "Incompetent Adult" means an adult who lacks sufficient capacity to manage his own affairs or to make or communicate decisions concerning his person, family, or property whether such lack of capacity is due to mental illness, mental retardation, epilepsy, cerebral palsy, autism, senility, disease, injury, or similar cause or condition.

(49) "Inmate of a Public Institution" means a person who lives in an institution that is the responsibility of a governmental unit or over which a governmental unit exercises administrative control and that provides treatment or services, food and shelter.

(50) "Institutionalized Spouse" means an individual who:

(a) is in a medical institution or nursing facility or who is described under 42 U.S.C. 1396a(a)(10)(A)(ii)(VI); and

(b) is married to an individual who is not in a medical institution or nursing facility; but does not include any such individual who is not likely to meet the requirements of Sub-item (a) of this Item for at least 30 consecutive days.

(51) "Life Estate Interest" means the right to use property and receive income from the property for the remainder of one's life.

(52) "Long-Term Care" means care in:

(a) general or specialty hospital in excess of 30 continuous days;

(b) a state mental hospital;

(c) a skilled nursing facility; or

(d) an intermediate care facility.

(53) "Patient Monthly Liability" means the amount of a long-term care patient's income that must be paid towards his cost of care.

(54) "Remainder Interest" means ownership interest in property that will be inherited in full or jointly with other remainder interest holders at a life interest holder's death.

(55) "Representative" means a person who is authorized by the client to act on behalf of the client.

(56) "Reserve" means assets owned by members of the budget unit and that have a market value.

(57) "Residence" means the county where a client lives with intent to remain for an indefinite time as governed by 10A NCAC 23E .0103. Also, an individual under age 21 has the residence of the person with whom he resides unless he is in the custody of a social services agency, in which case he is a resident of the county of the custodial agency.

(58) "Revocable Trust" means funds held in trust that are available for the client's use.

(59) "RSDI (Retirement, Survivors, Disability Insurance)" means social security benefits.

(60) "SDX" means State Data Exchange with the Social Security Administration for the purpose of providing a listing of all persons receiving supplemental security income, their current payment status and amount of SSI and other sources of income.

(61) "SSI" means Supplemental Security Income, a federal assistance payment for aged, blind and disabled persons administered by the Social Security Administration.

(62) "Stepparent" means that a person is not the parent of a child but the person is married to the parent of the child who wants to receive Medicaid.

(63) "Timely Notice" means the same as "Advance Notice".

(64) "Time Standard" means the requirement to process an application within 45 or 90 days from the date of application in accordance with 42 C.F.R. 435.911.

(65) "Verification" means the confirmation of facts and information used in determining eligibility.

10A N.C. Admin. Code 23A .0102

Authority G.S. 108A-25(b); 108A-54; P.L. 99-509; P.L. 100-360; P.L. 100-485; 42 C.F.R. 431.211; 42 C.F.R. 431.214; Alexander v. Bruton, U.S.D.C., File No. C-C-74-183-M, Consent Order dismissed effective February 1, 2002;
Eff. September 1, 1984;
Amended Eff. August 1, 1990;
Temporary Amendment Eff. March 1, 2003;
Amended Eff. August 1, 2004;
Transferred from 10A NCAC 21A .0201 Eff. May 1, 2012;
Pursuant to G.S. 150B-21.3A, rule is necessary without substantive public interest Eff. July 23, 2016;
Amended Eff. May 1, 2022; March 1, 2020.

Amended by North Carolina Register Volume 36, Issue 23, June 1, 2022 effective 5/1/2022.