Department of Human Resources

*** **** ******** ******

Baltimore MD 21201

FIA ACTION

TRANSMITTAL

Control Number: #02-54

Effective Date: April 1, 2002

Issuance Date: March 15, 2002

TO: DIRECTORS, LOCAL DEPARTMENT OF SOCIAL SERVICES

DEPUTY/ASSISTANT DIRECTORS FOR FAMILY INVESTMENT

FAMILY INVESTMENT SUPERVISORS/ELIGIBILITY STAFF

FROM: CHARLES HENRY, EXECUTIVE DIRECTOR, FIA

JOSEPH DAVIS, EXECUTIVE DIRECTOR, DHMH/OOE

RE: SIMPLIFIED REDETERMINATION PROCESS FOR COMBINED QMB/SLMB AND FOOD STAMP HOUSEHOLDS.

PROGRAMS AFFECTED: MEDICAL ASSISTANCE (MA), FOOD STAMPS (FS)

ORIGINATING OFFICE: OFFICE OF POLICY, RESEARCH AND SYSTEMS

BACKGROUND:

For the past two years the Departments of Aging (DOA), Health and Mental Hygiene (DHMH) and Human Resources (DHR) have worked together conducting extensive outreach to the Medicare eligible population. The goal is to increase awareness of other Medical Assistance programs available for individuals who receive Medicare. In addition, the outreach hoped to increase the number of individuals receiving Qualified Medicare Beneficiaries (QMB) or Specified Low-Income Medicare Beneficiaries (SLMB) benefits. In March 2000, interviewers began using a streamlined application in community and home-based settings. The outreach effort was successful and substantially increased QMB/SLMB participation.

A form was specifically designed for Medicare Beneficiaries entitled, “Redetermination for Medicare Beneficiaries,” (DES 9201). The simplification of the redetermination process for QMB/SLMB recipients who also receive Food Stamp benefits has expanded the outreach effort. A redetermination for Food Stamp Benefits form is included with the Medicare Beneficiaries redetermination form. This change provides customers with the opportunity to file one form for both programs eliminating the duplication of the redetermination process in local departments. The new form is yellow.

ACTION REQUIRED:

Beginning with the redetermination packages mailed out at the end of March, QMB/SLMB recipients will receive the DES 9201 Medicare Beneficiaries redetermination application including the Food Stamp redetermination form. Medical Assistance policy does not require a face-to-face interview for QMB/SLMB customers filing redetermination applications. The customer completes the combined redetermination application and forwards it to their local department of social services.

Upon receiving the combined application for QMB/SLMB and FS, the case manager

initiates the redetermination on CARES for both programs.

NOTE:

Customers who have completed the DES 9201 Medicare Beneficiaries redetermination application are not required to complete a separate 9707 Rights and Responsibilities form.

FOOD STAMPS

There is no change in FS policy. This process simplifies the redetermination procedures within the specified policy guidelines for combined QMB/SLMB and FS applications. It does not replace the food stamp application process.

If a customer who does not already receive food stamps completes the one page FS redetermination form, the case manager should mail the customer a 9701 application form to give them an opportunity to apply for benefits.

Policy Reminders

The case manager must review the application and determine the household composition and status prior to scheduling a redetermination interview. Food Stamp policy allows face to face interviews to be waived in favor of a telephone interview under certain circumstances, which include:

1.Illness,

2.Transportation difficulties,

3.Residency in a rural area,

4.Care of a household member,

5.Prolonged severe weather, or

6.Work or training hours that prevent a household from participating in a face-to-face interview.

Many of these households will qualify for a hardship exemption. There is no requirement to verify the hardship situation in order to waive the face to face interview.

In addition, local departments have the option of not interviewing households at the interim recertification. This cannot be on a case-by-case basis. Local departments choosing this option must establish who will be required to have a face to face interview and who will not.

The case manager will certify households for the appropriate length of time and can certify households, in which the adult household members are aged or disabled individuals, for up to 24 months following guidelines set in each local department. Households certified for FS for 24 months must have contact with the LDSS every 12 months. The certification date for the QMB/SLMB and the FS may be matched so that the FS contact and the QMB/SLMB redetermination occur at the same time.

For additional clarification regarding hardship determinations for waiving the face to face interview please refer to Section 402.4 of the Food Stamp manual. For clarification regarding 24-month certifications please refer to Section 410.1 of the Food Stamp manual.

INQUIRIES:

Please direct QMB/SLMB questions to Barbara Washington at 410-***-****, Food Stamp inquiries to Marilyn Lorenzo at 410-***-**** and policy inquiries to Deborah Weathers at 410-***-****.

Attachment

cc: DHMH Management Staff

DHR Executive Staff

FIA Management Staff

Constituent Services

DHR Help Desk

RESI

State of Maryland

Department of Health and Mental Hygiene

Redetermination for Medicare Beneficiaries

Only persons who receive Medicare benefits may use this redetermination form. This form may be used only by individuals and couples who are currently receiving benefits as Qualified Medicare Beneficiaries (QMB), Specified Low Income Medicare Beneficiaries (SLMB), or Qualified Individuals (QI). This form must be used for continuation of any of the following benefits:

·Payment of monthly Medicare Part A and Part B premiums or

partial reimbursement of Medicare premiums

·Payment of Medicare co-payments and deductibles

If you are receiving food stamps and want to continue to get them, you may also complete the food stamp application included with this form.

If you need help with old medical bills, or if you want to apply for complete Medical Assistance coverage, you should call your case manager right away and ask for an application for Medical Assistance.

You are providing personal information (Name, Address, Date of Birth, Income History, Employment History, etc.) in this application for benefits.

The purpose of requesting this personal information is to determine your eligibility for benefits. If you do not provide this personal information, the Medical Care Program may deny your application for benefits. You have a right to inspect, amend or correct this personal information. The Medical Care and Food Stamp Programs will not permit inspection of your personal information, or make it available to others, except as permitted by Federal and State law.

Please answer all of the questions on this form as best you can. If more information is needed you will be contacted by telephone or mail.

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DES 9201

Rights and Responsibilities

I agree to the release of personal and financial information from my application to agencies determining eligibility for the Medical Care or Food Stamp Program so that they can evaluate it and determine eligibility. I understand that I may be asked to provide additional information. I have the right to appeal any decision made concerning my eligibility. Officials of the Department of Human Resources and The Department of Health and Mental Hygiene may verify all information on this form. I understand that I must tell the agency that determines my eligibility about any changes in the information reported on my application within 10 days after the changes. By signing the application form, I certify under penalty of perjury that everything on the form is the truth as best I know it.

I certify that everyone requesting benefits on this application form is a U.S. citizen or lawfully admitted alien. Proof of lawful immigration status may be required.

All information and documentation gathered for determining eligibility are confidential. Disclosure of information concerning eligibility to anyone not authorized to receive it is a violation of State and Federal laws.

I understand that I am required by law to assign to the State all third party payments (hospital and medical benefits) and to cooperate with the State in securing such payments. I also understand that the State may recover from the estate of any person over 55 years old an amount not to exceed the amount of benefits paid out on behalf of that person. There will be no recovery from the estate of a deceased individual with a surviving spouse.

I understand that the programs will use social security numbers to verify information such as income and insurance and to help maintain files regarding eligibility and payments. The information may be matched with records in other agencies, such as the Social Security Administration or the Internal Revenue Service.

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Redetermination for Medicare Beneficiaries

Please print

Section 1. Information about you.

Your Name:

First Middle Last

Address:

Street Address Apt. No.

City State Zip Code

Telephone Number: -

Date of Birth: Sex: Male Female Race:

Your Social Security Number: - -

Medicare Number: - - -

Marital Status: Never Married Married and living with spouse

Divorced Separated Widowed

Are you a Maryland resident? Yes No

Are you a citizen of the U.S.? Yes No

If not a citizen, date of arrival in the U.S.: INS ID Number:

Which language do you speak the most? English Spanish Other:

Section 2. Information about your spouse.

If you are living with your spouse, please complete the following information about him or her.

** Provide the Social Security number and citizenship information only if you are applying for QMB/SLMB or Food Stamps for him or her.

Name:

First Middle Last

Date of Birth: Race:

**Social Security Number: - -

Medicare Number : - - -

**Is this person a citizen of the U.S.? Yes No

If not a citizen, date of arrival in the U.S.: INS ID Number

Section 3. Income.

Type of Income

Amount

How Often

(Monthly, weekly, etc)

Received by:

Applicant Spouse

Social Security

$

Social Security (SSI)

$

Veteran’s Benefits

$

Railroad Retirement

$

Civil Service Annuity

$

Pension

$

Rental Income

$

Mortgage Income

$

Interest on account

$

Job Earnings

$

Alimony

$

Other:

$

$

Section 4. Assets.

Type

Name of bank or institution, or location

Owner:

Applicant Spouse

Current

Value

Savings

$

Checking

$

Stocks

$

Bonds

$

Real Estate

$

Burial or Funeral Plan

$

IRA

$

Trust Fund

$

Other:

$

Section 5. Life Insurance

Insured Person

Insurance Company

Policy Number

Face Value

Cash Value

$

$

$

$

$

$

$

$

Section 6. Health Insurance

Insured Person

Insurance Company

Policy Number

Section 7. Authorized Representative. This section is optional. Complete it only if you want someone else to handle your Medical Care Program eligibility for you.

You may have another person, such as a relative, friend or attorney, to represent you in your application for benefits. If you would like that person to speak to the Department about your case and receive copies of all letters about your eligibility, please fill in the following:

Name of representative:

Address of representative:

Daytime telephone: - Evening telephone: -

Representative’s relationship to you:

I would like the representative above to: (check all that apply)

Receive copies of all letters about my eligibility, and to discuss my eligibility with the Department of Social Services and the Department of Health and Mental Hygiene.

Receive and complete my annual applications for me.

Receive my identification card for me.

I have received a copy of my rights and responsibilities. I understand my responsibilities and agree to cooperate with the State as required. Everything in this application is true and complete to the best of my knowledge.

Signature of Applicant Date

Signature of any Representative Date

Redetermination for Food Stamp Benefits

If you are getting food stamps and want to continue getting them, complete sections 8 through 11.

If you are not getting food stamps and want to apply, contact your local department of social services.

Section 8. Shelter Costs

Is anyone in your household paying for any of the following? Check all those paid and answer the questions.

Expenses

Amount

How Often?

Who Pays?

Rent

Mortgage

Electric

Gas

Oil

Coop or Condo Association fees

Telephone

Water

Sewer

Garbage

Wood/Coal

Property Tax

Homeowner’s Insurance

Other

Is heat included in your rent? ÿ Yes ÿ No

Do you pay an electric bill for lights or cooking? ÿ Yes ÿ No

If heat is not included in the rent, what is your source of heat?

Do you pay for air conditioning? ÿ Yes ÿ No

Does someone help you with your utility costs? ÿ Yes ÿ No

If yes, who?

Are you sharing any of the shelter costs listed above? ÿ Yes ÿ No

If yes, with whom? Your Share?

Have you received Energy Assistance at your current address within the past 12 months?

ÿ Yes ÿ No

Section 9. Dependent Care

If anyone in your household pays someone to care for a disabled adult, fill in this section:

Name of Care Provider

Telephone

Number Street

City State Zip code

Household Member Receiving Care

Who Pays?

Cost

$

Section 10. Medical Expenses

Food Stamps – Does any household member pay medical expenses for any person age 60 or over, or any person receiving disability benefits? ÿ Yes ÿ No

If yes, check the appropriate box and list the monthly amount you pay.

ÿ Health/Medicare Insurance $ ÿ Medical/Dental Insurance $

ÿ Dentures/Glasses/Hearing Aids $ ÿ Transportation Costs $

ÿ Hospital $ ÿ Nursing $

ÿ Attendant Care $ ÿ Pharmacy Expense $

Section 11. Household’s Declaration

1.Has any member of your household ever been convicted of a felony offense after August 22, 1996 that involved drugs?

ÿ Yes ÿ No If yes, who?

2.Is any member of your household currently violating parole or probation or fleeing from the policy of the courts?

ÿ Yes ÿ No If yes, who?

3.Has any member of your household been convicted since August 22, 1996 in a Federal or State Court for misrepresenting where they lived or their identify in order to receive Food Stamp benefits or Cash Assistance from more than one place in the same month?

ÿ Yes ÿ No

4.Has any member of your household been convicted by a court of trafficking Food Stamp

benefits of $500 or more?

5.Are you or any member of your household receiving benefits under another identity or as a member of another household or in another State?

ÿ Yes ÿ No If yes, who?

Rights and Responsibilities

I agree to the release of personal and financial information from my application to agencies determining eligibility for the Medical Care and Food Stamp Programs so that they can evaluate it and determine eligibility. I understand that I may be asked to provide additional information. I have the right to appeal any decision made concerning my eligibility. Officials of the Department of Human Resources and the Department of Health and Mental Hygiene may verify all information on this form. I understand that I must tell the agency that determines my eligibility about any changes in the information reported on my application within 10 days after the changes. By signing the application form, I certify under penalty of perjury that everything on the form is the truth as best I know it.

I certify that everyone requesting benefits on this application form is a U.S. citizen or lawfully admitted alien. Proof of lawful immigration status may be required.

All information and documentation gathered for determining eligibility are confidential. Disclosure of information concerning eligibility to anyone not authorized to receive it is a violation of State and Federal laws.

I understand that I am required by law to assign to the State all third party payments (hospital and medical benefits) and to cooperate with the State in securing such payments. I also understand that the State may recover from the estate of any person over 55 years old an amount not to exceed the amount of benefits paid out on behalf of that person. There will be no recovery from the estate of a deceased individual with a surviving spouse.

I understand that the programs will use social security numbers to verify information such as income and insurance and to help maintain files regarding eligibility and payments. The information may be matched with records in other agencies, such as the Social Security Administration or the Internal Revenue Service.

About my Redetermination

I am now eligible as a Qualified Medicare Beneficiary (QMB), Special Low Income Beneficiary (SLMB), or Qualified Individual (QI). I understand that these benefits do not cover all of my medical expenses, but may help me to pay my Medicare premiums, deductibles and co-payments.

I understand that if I need help with other medical expenses, I must contact my case manager at the Local Department of Social Services.

I mailed my redetermination form on .

I mailed my redetermination form to:

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