Instructions for Form 223 Attachment A "Medicaid and IV-E Application" - Georgia (United States)

This document contains official instructions for Form 223 Attachment A, Medicaid and IV-E Application - a form released and collected by the Georgia Department of Juvenile Justice. An up-to-date fillable Form 223 Attachment A is available for download through this link.

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Download Instructions for Form 223 Attachment A "Medicaid and IV-E Application" - Georgia (United States)

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MEDICAID AND IV-E APPLICATION
FORM 223-DJJ INSTRUCTIONS (Revised 4/13)
PURPOSE:
Form 223 is to be used by the JPPS or DJJ Case Expeditor to apply for Medicaid and to request a IV-E determination on behalf of a DJJ
youth who has been detained and awaiting non-secure placement or who is currently placed in an out of home placement following
screening or adjudication of charges. An application should be completed within five (5) working days of the child’s placement. The
JPPS should provide information for all questions to the extent possible.
INSTRUCTIONS:
YOUTH’S INFORMATION: The youth’s name should be listed as it appears on the Birth Certificate. The fields for SSN, date of birth,
gender and race are self-explanatory. Eligibility requires documentation be provided for all non-citizens; Qualified Aliens, Qualified
Immigrants. A Birth Certificate is required documentation for citizenship. Provide all information known on child’s mother and father
including address, SSN, race, DOB, legal relationship and paternity. Indicate the date youth was detained or placed and whether or not
the youth is jointly committed to DJJ and in DFCS custody.
MEDICAID INFORMATION SECTION:
Prior Months Medicaid Needed? Is Medicaid needed for any of the three months prior to the application month? List month(s), year(s).
Questions 1 and 2. Indicate whether or not youth receives income and indicate the type of income, i.e. SSI (Social Security Income paid
to persons who are aged, blind or disabled); RSDI (Federal funds paid to persons age 62 or over or to disabled persons and their
dependents. RSDI may be paid on behalf of a deceased family member); Child Support (Child Support can be received directly or
through DCSS and is counted as income to the youth regardless of who receives the child support payment); Other (earned income from
part-time or full-time employment). Income should be entered as gross income. Indicate the amount and frequency of youth’s income.
Indicate whether or not youth has any resources. Resources include a car, cash on hand, bonds, checking account or savings account.
Indicate the type and amount of resource(s). The youth’s income and resources should also be addressed on the Form 224 DJJ, Removal
Home Income and Asset Checklist, which should accompany the Form 223 DJJ.
Question 3. Indicate whether or not youth is pregnant. A copy of verification of pregnancy and estimated date of delivery must be faxed
with this form to insure the appropriate Medicaid coverage is provided to pregnant youth.
Question 4. Indicate whether or not youth is covered by health insurance other than Medicaid/PeachCare. A copy of the insurance card
(front and back) should be faxed along with the 223 DJJ form. Please provide the name of the insurance company, group/ID #, name of
the insured and the relationship to the youth.
IV-E INFORMATION SECTION:
Court orders with referenced complaints/petitions should accompany the 223 DJJ form or be uploaded in JTS. Examples of court orders
needed are detention order, commitment order, adjudication orders, etc.
Question 4a. List the name of the person the youth was physically living with at the time of the removal (when youth entered RYDC
and/or placement).
Question 4b. Indicate if the person named in 4a. is a parent, relative or other. If relative or other is checked, specify the relationship to
the youth.
Question 4c. List the individual indicated on the complaint or petition identified as having custody of the youth.
Question 4d. If this is the same person listed in 4a, indicate “Yes”. If the answer is no, did the youth live with the person listed in 4c
within the 6 months prior to the removal from the home. If youth lived with the individual within the 6 months, list the month(s) that
youth lived with the person. List everyone living in the home at time the youth was removed along with their DOB, Relationship to the
youth, Gender, Race and SSN.
Question 5. Deprivation results when one or both parents are out of the home due to continued absence from the home (separated/
divorced parents who not living in the same home) or death. Deprivation can also exists when both parents are in the home due to the
incapacity of one or both parents or unemployment of one of both parents. If deprivation is indicated due to unemployed parent(s), the
Eligibility Specialist may require further information from the JPPS. Answer all the Deprivation questions and indicate which parent.
Question 6. Provide the name and street address of youth’s current placement and indicate the type of placement.
Question 7. Indicate the date of the Juvenile Court complaint or petition. Provide the date of the court hearing addressing complaint
and/or petition. Provide Judge’s name.
Question 7a. Does the court order contain “contrary to welfare/best interest” language along with specifics as to why it is contrary to the
welfare for the youth to remain in the home or in the best interest that the youth be removed from the home (Are the child specifics listed
in the complaint/petition referenced in the removal order?)? Indicate “Yes” or “No”
DJJ 24.1 Attachment B: DJJ Form223 Instructions-Rev. 05/2013
MEDICAID AND IV-E APPLICATION
FORM 223-DJJ INSTRUCTIONS (Revised 4/13)
PURPOSE:
Form 223 is to be used by the JPPS or DJJ Case Expeditor to apply for Medicaid and to request a IV-E determination on behalf of a DJJ
youth who has been detained and awaiting non-secure placement or who is currently placed in an out of home placement following
screening or adjudication of charges. An application should be completed within five (5) working days of the child’s placement. The
JPPS should provide information for all questions to the extent possible.
INSTRUCTIONS:
YOUTH’S INFORMATION: The youth’s name should be listed as it appears on the Birth Certificate. The fields for SSN, date of birth,
gender and race are self-explanatory. Eligibility requires documentation be provided for all non-citizens; Qualified Aliens, Qualified
Immigrants. A Birth Certificate is required documentation for citizenship. Provide all information known on child’s mother and father
including address, SSN, race, DOB, legal relationship and paternity. Indicate the date youth was detained or placed and whether or not
the youth is jointly committed to DJJ and in DFCS custody.
MEDICAID INFORMATION SECTION:
Prior Months Medicaid Needed? Is Medicaid needed for any of the three months prior to the application month? List month(s), year(s).
Questions 1 and 2. Indicate whether or not youth receives income and indicate the type of income, i.e. SSI (Social Security Income paid
to persons who are aged, blind or disabled); RSDI (Federal funds paid to persons age 62 or over or to disabled persons and their
dependents. RSDI may be paid on behalf of a deceased family member); Child Support (Child Support can be received directly or
through DCSS and is counted as income to the youth regardless of who receives the child support payment); Other (earned income from
part-time or full-time employment). Income should be entered as gross income. Indicate the amount and frequency of youth’s income.
Indicate whether or not youth has any resources. Resources include a car, cash on hand, bonds, checking account or savings account.
Indicate the type and amount of resource(s). The youth’s income and resources should also be addressed on the Form 224 DJJ, Removal
Home Income and Asset Checklist, which should accompany the Form 223 DJJ.
Question 3. Indicate whether or not youth is pregnant. A copy of verification of pregnancy and estimated date of delivery must be faxed
with this form to insure the appropriate Medicaid coverage is provided to pregnant youth.
Question 4. Indicate whether or not youth is covered by health insurance other than Medicaid/PeachCare. A copy of the insurance card
(front and back) should be faxed along with the 223 DJJ form. Please provide the name of the insurance company, group/ID #, name of
the insured and the relationship to the youth.
IV-E INFORMATION SECTION:
Court orders with referenced complaints/petitions should accompany the 223 DJJ form or be uploaded in JTS. Examples of court orders
needed are detention order, commitment order, adjudication orders, etc.
Question 4a. List the name of the person the youth was physically living with at the time of the removal (when youth entered RYDC
and/or placement).
Question 4b. Indicate if the person named in 4a. is a parent, relative or other. If relative or other is checked, specify the relationship to
the youth.
Question 4c. List the individual indicated on the complaint or petition identified as having custody of the youth.
Question 4d. If this is the same person listed in 4a, indicate “Yes”. If the answer is no, did the youth live with the person listed in 4c
within the 6 months prior to the removal from the home. If youth lived with the individual within the 6 months, list the month(s) that
youth lived with the person. List everyone living in the home at time the youth was removed along with their DOB, Relationship to the
youth, Gender, Race and SSN.
Question 5. Deprivation results when one or both parents are out of the home due to continued absence from the home (separated/
divorced parents who not living in the same home) or death. Deprivation can also exists when both parents are in the home due to the
incapacity of one or both parents or unemployment of one of both parents. If deprivation is indicated due to unemployed parent(s), the
Eligibility Specialist may require further information from the JPPS. Answer all the Deprivation questions and indicate which parent.
Question 6. Provide the name and street address of youth’s current placement and indicate the type of placement.
Question 7. Indicate the date of the Juvenile Court complaint or petition. Provide the date of the court hearing addressing complaint
and/or petition. Provide Judge’s name.
Question 7a. Does the court order contain “contrary to welfare/best interest” language along with specifics as to why it is contrary to the
welfare for the youth to remain in the home or in the best interest that the youth be removed from the home (Are the child specifics listed
in the complaint/petition referenced in the removal order?)? Indicate “Yes” or “No”
DJJ 24.1 Attachment B: DJJ Form223 Instructions-Rev. 05/2013
Question 7b. Is there a court order that addresses “reasonable efforts to prevent removal” along with agency specific examples of
reasonable efforts provided to/for the youth (i.e. probation services, counseling services, etc.)? Was this language obtained in a court
order within 60 days of youth’s removal? Indicate “Yes” or “No” and indicate the date of the court hearing. Provide Judge’s name.
Form 223 DJJ must be signed and dated by the JPPS. This form will be used as a Medicaid application.
The Eligibility Specialist will also sign Form 223 DJJ and indicate date the form was received.
Fax or e-mail the completed form to the appropriate Eligibility Specialist along with the following:
Form 224 DJJ, Removal Home Income and Asset Checklist
Copy of the youth’s Birth Certificate; Copy of the youth’s Social Security Card
Copy of court order(s) as well as copy of the complaint and/or petitions indicated in court order(s) (if not uploaded in JTS)
Copy of front and back of insurance card(s) if applicable
DJJ 24.1 Attachment B: DJJ Form223 Instructions-Rev. 05/2013
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