`subchapter 23g medicaid certification, correction of eligibility and redetermination of eligibility


section .0100 medicaid certification



(a) Certification.

(1) Certification periods shall be for:

(A) One, two or three months if a medical service covered by the state's program was received in the three months prior to the month of application and the client would have been eligible had he applied; or

(B) Not more than four months for AFDC cases terminated due to child care; or

(C) Six months for medically needy clients, clients in long term care, with income other than or in addition to SSI, Family and Children's cases and children in county custody or for whom the county has placement responsibility, and categorically needy aged, blind or disabled clients who have deductibles or unstable incomes; or

(D) Twelve months for categorically needy aged, blind or disabled clients who are in a private living arrangement and have no deductible and whose incomes are stable, clients who are in long term care and have no income other than SSI and children in county custody or for whom the county has placement responsibility who have no deductible and who have stable income; or

(E) Not more than six months for AFDC cases terminated for the increased earnings or hours of employment; or

(F) Twelve months for categorically needy clients receiving Special Assistance for the Blind; or

(G) Twelve months for M-IC cases and children who are born to Medicaid eligible women as described in 10A NCAC 23D .0101(6) or through month of next birthday, whichever is earlier; or

(H) A lesser number of months if the client dies before the application is completed or if the client is a budget unit member of another case and the months remaining in the certification period for that case are less than six or twelve months as stated in (a)(1)(C) or (D) of this Rule.

(I) Begin M-PW certification with first month of M-PW coverage and end on the last day of month in which falls the 60th day after the termination of pregnancy.

(2) Certification periods shall begin:

(A) With the first month of retroactive medical need except that if the months are not consecutive, each month is a separate certification period; or

(B) With the month of application except that if application is made in anticipation of a future medical need within the application processing period, the certification begins with the month of medical need; and

(C) On the first day of the month of certification as stated in (a)(2)(A) and (B) of this Rule.

(3) Certification is established when a client meets all conditions of eligibility for the program except that he must incur medical expenses equal to the amount by which his income exceeds the income levels.

(4) Certification shall be terminated when the client's predicted medical expenses not subject to payment by a third party indicate that he cannot meet the amount of his deductible.

(5) A twelve month certification period shall be adjusted to two six month periods when a change in the client's situation results in his having a deductible or his income becomes unstable.

(6) Certification periods shall run consecutively unless the client's case is terminated and he reapplies at a later date. Certification periods shall not overlap except that months included in a previous application which was denied, may be included as retroactive months in a new application.

(b) Authorization.

(1) Eligibility shall be authorized when a client meets all conditions of eligibility, including meeting a deductible if one is required.

(2) The period authorized shall be the portion of the certification period for which all conditions of eligibility are met.

(3) The beginning and ending dates of the authorization period are stated in 10A NCAC 21B .0204.


History Note: Authority G.S. 108A-54; 42 C.F.R. 435.112; 42 C.F.R. 435.914;

Eff. September 1, 1984;

Amended Eff. March 1, 1993; August 1, 1990;

Transferred from 10A NCAC 21B .0405 Eff. May 1, 2012.