10A N.C. Admin. Code 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.
Notes
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.
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. March 1, 2020.
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