ICAMA Forms

The day-to-day administration of the ICAMA is done by state professionals using the ICAMA forms.

ICAMA 7.02 and 7.02b

The ICAMA 7.02 is the NOTICE TO FAMILIES and is sent to the adoptive parents or guardians. Included with the ICAMA 7.02 are a copy of the ICAMA 6.01 (Notice of Medicaid Eligibility/Case Activation) that was sent to the new Residence State and the 7.02b Important Information for Families.

TheICAMA 7.02b IMPORTANT INFORMATION FOR FAMILIES helps parents or guardians better understand the interstate process.

The ICAMA 7.02 is now available in Spanish.
The ICAMA 7.02b is now available in Spanish.

ICAMA form 7.02 in English and Spanish were effective July 30, 2012.

The ICAMA 7.02 and 7.02b were revised in January 2015 to reflect that fact that effective January 2014 New Hampshire provides Medicaid services for children living in New Hampshire with state-funded adoption assistance agreements (AAA) signed by other states.

ICAMA 7.5 series

ICAMA 7.5

The purpose of the 7.5 form is facilitate communication between the Agreement and Residence states about changes to the information in a case opened with ICAMA 6.01.

The ICAMA 7.5 is divided into two sections.

  • Basic information including Agreement State and Resident State contact information and Child Identifying and eligibility information
  • State information exchange about an existing ICAMA case. (Case was opened with the ICAMA 6.01)
    1. notification that Medicaid case is open
    2. extension of eligibility
    3. address change
    4. case changes
    5. change of Social Security Number

ICAMA 7.5 Additional
The purpose of the ICAMA 7.5 Additional is allow more than one child to be included in the information exchange indicated on the ICAMA 7.5.
The ICAMA 7.5 Additional is not a stand-alone form and is used only in conjunction with the ICAMA 7.5.

ICAMA 7.5 Explanatory Information
The purpose of the ICAMA 7.5 Explanatory Information is to provide information for ICAMA Professionals that may help in completing the ICAMA 7.5

 

ICAMA 6.01

The ICAMA 6.01 was withdrawn on February 26, 2015 and was replaced by the ICAMA 700 Form.


ICAMA 6.02

The ICAMA 6.02 was withdrawn on July 27, 2012 and was replaced by the ICAMA 7.02.

ICAMA 6.03

The ICAMA 6.03 was withdrawn as of December 1, 2014 and wass replaced by the ICAMA 7.5 series

 

 

 

 

Updated: February 26, 2015