North Carolina Administrative Code › Title 10A - HEALTH AND HUMAN SERVICES › Chapter 23 - MEDICAL ASSISTANCE ADMINISTRATION › Subchapter A - GENERAL PROGRAM ADMINISTRATION › Section .0100 - GENERAL › Section 23A .0102 - DEFINITIONS

Current through Register Vol. 39, No. 2, July 15, 2024
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.