All Medicaid Programs |
Obsolete Policy |
End Date: December 31, 2013
No Previous Policy
Whenever applicants or recipients decide that they do not want to cooperate with Medical Support Enforcement requirements they must be given the opportunity to claim good cause before a sanction is applied.
The applicant or recipient may indicate that he or she wants to claim good cause by signing the good cause box on the ORS/CSS application form or marking and signing the good cause box on the form 619-D or by telling the eligibility worker that he or she wants to claim good cause.
The eligibility worker or the supervisor must complete a Form 124GC, Good Cause Verification and give a copy to the applicant/recipient. The 124GC explains the good cause reasons and what information/evidence the applicant/recipient must provide. The information and/or evidence must be provided within 20 days of the request.
Once the applicant/recipient has provided information or evidence to indicate that good cause may exist under one of the circumstances listed in Section 227-3, do not deny, delay, or discontinue Medicaid coverage while waiting for the applicant/recipient to provide additional evidence or while a determination of good cause is being made.
The supervisor will evaluate the claim, monitor the processing and make the final decision on the claim.
Use the Form 619-C, Good Cause Check List, to track the good cause process and as a guide to determine proper coding on the MASD screen in PACMIS.
Initial Documentation and Evaluation of Good Cause Claim
Immediately notify ORS/CSS of the good cause claim according to the local office pathway. Enter the code 'PD' on the MASD screen in PACMIS.
The local office supervisor will make the initial determination based on evidence provided by the applicant/recipient and/or any information available in agency records. The supervisor must approve or deny the initial good cause claim within thirty days from the date of the initial request.
Note: If the applicant/recipient withdraws the good cause claim at any time, enter the 'GW' on MASD.
Initial Decision - Evidence Supports Good Cause Claim
If an initial decision is reached that the good cause claim is valid, immediately send a copy of the evidence/investigation material to ORS/CSS for review and comment. Record the initial decision on the 619-C and the CAAL screen. Change the code on the MASD screen to 'GC' to indicate that the Supervisor recommends that the good cause claim be approved.
ORS/CSS should respond to the supervisor's proposed decision within ten working days by sending a worker alert on PACMIS. If ORS/CSS agrees with the decision, the alert will state "ORS-GC Approved." If ORS/CSS disagrees with the decision or agrees but wants to pursue support, the alert will refer the worker to a notice on the WNHS screen. The notice will list possible actions the local office may take on the good cause claim. If a response is not received from ORS/CSS within ten working days, the supervisor should contact the ORS/CSS manager by phone and then proceed with the good cause determination.
The supervisor will make the final determination. The supervisor must consider any recommendations made by ORS/CSS, including recommendations about proceeding with Medical Support Enforcement activities without the client's cooperation, when making the final determination of good cause. A final determination must be made within 45 days of the date of the original request.
Once the final determination is made, enter the corresponding code on the PACMIS MASD screen, 'GA' for Good Cause Approved, 'GD' for Good Cause Denied. If a decision was made that Good Cause exists but ORS/CSS can proceed with Medical Support Enforcement, leave the 'GC' code.
If good cause is approved and ORS/CSS will not proceed with Medical Support Enforcement, send the GIGA notice.
If good cause is approved, but ORS/CSS will proceed with Medical Support Enforcement without the cooperation of the individual, send the GICP notice. Allow the individual an additional ten days to respond to the notice.
(1) If the client agrees with the decision to proceed with Medical Support Enforcement, enter the 'GP' code on MASD.
(2) If the client disagrees with the decision to proceed with Medical Support Enforcement, the client may request a hearing. If a hearing is requested, change the coding on MASD to 'GH'. This will alert ORS/CSS that the client has filed a hearing and they should not proceed with Medical Support Enforcement until the hearing is resolved.
(3) If the client does not request a hearing, determine if he or she wants the case to remain open. Explain that if the case remains open, ORS/CSS will proceed with Medical Support Enforcement.
(4) If the client does not want the case left open, or does not respond to the GICP notice, change the coding on MASD to 'GP' and close the case. Use the closure code RC or IV. Send the proper closure notice.
Initial Decision - Insufficient Evidence to Support Good Cause Claim
If the supervisor determines that the evidence does not support the claim of good cause, change the coding on MASD to 'GD' and send the ALMD notice. Allow the claimant an additional ten days to cooperate, appeal the decision, withdraw the application, or request that he/she be removed from the case. The notice must tell the client what the sanction will be for non-cooperation. (See Section 227-6 for further information regarding sanctions.)
If the client responds to the notice and indicates he/she is now willing to cooperate, have the client complete the ORS/CSS application or refer him or her to the ORS/CSS worker and change the coding on MASD to 'GW'.
If the client does not respond to the notice within ten days, or still refuses to cooperate, leave the 'GD' code on the MASD screen and send the MBCD notice to inform the client of when the sanction will begin. Code the non-cooperating person 'DI' on SEPA and determine eligibility for the rest of the household. Send any Medical Support Enforcement information you have to ORS/CSS.
If the client requests a hearing, change the coding to 'GH' on MASD. This will alert ORS that the client has filed a hearing and that they should not proceed with Medical Support Enforcement until the hearing is resolved. The client can request a hearing by completing Form 490. (See Section 125 for information about hearings.)
If the client requests the case be closed/denied, leave the 'GD' code on the MASD screen and close or deny the case. Narrate on CAAL that the Medical Support Enforcement issue needs to be resolved if the client reapplies. Notify the client of the case closure or denial.