Medicaid Policy                                                                 

811 Notification

Effective Date: September 1, 2015

Previous Policy

 

A. Notice Requirements

The agency must provide all applicants and recipients with a written notice of:

• the decision on an application or review;
• any action to terminate, discontinue, or suspend a member's medical assistance;
• any action that changes the form or amount of benefits;
• any request for information or verifications needed to determine eligibility.  

1. Notice to Approve or Increase Benefits

1. The eligibility agency must notify a member whenever it approves the member's application or renews the member's eligibility at review for medical assistance benefits.  The agency must notify the member of any positive action affecting the form or amount of the member's benefits, such as a decrease in a spenddown or premium.      
2. A notice to approve or renew eligibility, or moving an individual to a better medical program does not require 10-day advance notice. The notice of a positive change can be sent after the effective date, but should be sent as soon as possible upon making a change. If making a change to UPP, see Section 1009.
3. A notice to approve or renew eligibility, or increase benefits must include the following information.

1. What action the agency is taking, i.e., approval of an application or review, decrease in a spenddown, or a change to a different medical program that allows a member to receive more medical services.
2. Who the action affects, and any differences in how each person is affected.  If an action affects everyone in the household in the same way, the notice does not have to name each person separately or explain the effect more than once.
3. The date such action is effective.

 

2. Adverse Action Notices

1. The eligibility agency must notify the member of an adverse action taken on an application or eligibility review, an increase in a spenddown, cost-of-care contribution or premium, or any other adverse change affecting the member's eligibility. 
2. For most adverse actions, the eligibility agency must send a notice at least 10 days before the effective date of the action.   
3. The agency must send the notice to a mailing address agreed upon by the member or the member’s representative.
4. A member can request to get copies of notices at the local office or electronically (MyCase).
5. An adverse action notice must include the following information:

1. What action the agency is taking, i.e., denial of an application; spenddown, cost-of-care contribution, premium or asset co-payment amount; increase in a spenddown, etc.; change to a different medical program that has less medical services available; termination of eligibility.
2. Who the action affects, and any differences in how each person is affected.  If an action affects everyone in the household in the same way, the notice does not have to name each person separately or explain the effect more than once.
3. The date such action is effective.
4. The reason for the action.
5. The basis of the verification for MAGI programs.
6. The policy citation, or the federal or state law or regulation that supports the action.
7. An explanation of the member's right to a fair hearing.

3. Notice Requirements When a Member Requests Continued Benefits During an Appeal.

A member can receive continued benefits when a member asks for a hearing any time before the effective date of the action or by the close of business on the 10th day after the date the Notice of Decision letter was received, whichever is later.  The date on which the notice is received is considered to be 5 days after the date printed on the notice, unless the member can show he did not receive the notice within that 5 day period.  (125-3)

4. Exceptions to 10-day Advance Notice

Negative action can be taken without giving the recipient 10-day advance notice in the following situations:

1. The recipient requests in writing that his case be closed.
2. The recipient has been admitted to an institution under governmental administrative supervision.
3. The recipient’s whereabouts are unknown and the post office returns mail indicating no forwarding address.
4. The local office has determined the recipient is receiving assistance in another state.
5. The local office has factual information confirming the death of a recipient.  In this instance, the notice must be mailed on the date the case closure is recorded in the case record.  The effective date of the closure is the date the person died.
6. The recipient has moved out of state and is not expected to return.

5. Five Day Advance Notice for Suspected Intentional Program Violation

If the facts indicate that there has been an intentional program violation by the recipient, send the notice of adverse action at least 5 days before the effective date of action.

6. Requesting Information or Verification

When the eligibility agency needs forms, information or verification from the individual to determine eligibility, the agency must send a written request to the individual.  The request must say what is required and the due date for providing the requested information, form or verification.  The notice must tell the individual he may ask for more time to respond and may ask the agency to help obtain information or verification if the individual cannot get it.

For policy about verifications, see sections 703-4 (applications), 721 (reviews), 731 (verifications), and 815 (changes).

7. Proper Notice for Renewals     

When individuals do not respond to requests to complete renewals, the agency gives 10-day notice for closure.  If the individual contacts the agency to before the end of the review month, benefits must be restored for the following month if there is a request for additional verification or workload prevents workers from re-determining eligibility timely.   

8. Use of Electronic Notices

1. 1. The eligibility agency must give applicants and recipients the option to receive notices and information through an electronic format. 
      1. Confirm by regular mail the individual’s choice to receive electronic notices.
      2. The individual may choose to receive notices through regular mail at any time.
   2. Electronic notices must be posted to the recipient’s account within 1 business day.
      1. Send an email or other electronic communication to alert the member that a notice has been posted.
   3. If the electronic notice is not transmitted successfully, send the notice by regular mail 3 days from the failed electronic notice date.
   4. At the member’s request, the eligibility agency must provide any notice by regular mail that had previously been posted electronically

                                                                                                                                                                                   

B. Informing Individuals of Hearing Rights

The eligibility agency must inform individuals of the right to ask for a fair hearing if the individual disagrees with an agency action, or does not make a timely decision on an application.  Individuals must be informed at application and any time the eligibility agency takes an action affecting the individual's eligibility.

The notices sent to individuals must explain:

• how the individual can ask for a hearing,
• how long the individual has to ask for a hearing,
• how a recipient may receive continued benefits while the hearing takes place, and
• that the individual may represent himself, or have a family member, friend, representative or attorney represent him.

 

C. Specific Long Term Care Notices

1. The agency must send a notice to individuals if eligibility for long-term care services is restricted because of imposition of a penalty period for transfer of assets, or because the individual has substantial home equity.

A notice about a penalty period for transferring assets must include:

1. The start and end dates of the penalty period,
2. The policy citation, or federal or state law or regulation that supports the action, and
3. The individual's right to request a hearing.  

2. A notice about restricting long-term care services because of substantial home equity must state when the restriction begins, the value of the home and the maximum allowed limit, and the individual's right to ask for a fair hearing.

3. The agency must notify individuals of the results of an Assessment of Assets completed for an institutionalized individual, or an individual applying for home and community based waiver services, and his or her spouse.  The notice must include the results of the assessment and information about the individual's right to request a fair hearing when the individual applies for Medicaid.

 

811-4 Returned Mail