All Medicaid Programs |
Obsolete Policy |
Claiming Good Cause
Whenever an applicant or recipient does not want to cooperate with Medical Support Enforcement requirements, explain the option to claim good cause. Applicants and recipients must be given the opportunity to claim good cause before applying a sanction.
Do not deny, delay or discontinue Medicaid coverage or apply any sanctions while a determination of good cause is being made. Proceed to make an eligibility decision for an applicant who claims good cause before requiring evidence. If a recipient originally agreed to cooperate and is now refusing, explain good cause and give the recipient the opportunity to claim good cause.
If the individual claims good cause, request information and evidence to indicate that good cause may exist under one of the good cause reasons listed below before applying a sanction.
Good Cause Reasons and Acceptable Evidence
The applicant or recipient may claim good cause in order to protect the best interests of the child or the parent/non-parent caretaker relative. The following are good cause reasons for not cooperating with Medical Support Enforcement requirements and examples of acceptable evidence:
The child for whom support is sought was conceived as a result of incest or rape.
Evidence includes: Birth certificates, medical, Department of Human Services/DCFS, court, or law enforcement records which verify that the conception of the child was due to incest or rape.
Legal proceedings for the adoption of the child are pending before a court of competent jurisdiction.
Evidence includes: Court documents, any Department of Human Services/DCFS records, letter from a licensed adoption agency or attorney.
A public or licensed private social agency is helping the individual resolve the issue of whether to keep or relinquish the child for adoption and the discussions have not gone on for more than three months.
Evidence includes: Written notice from the public or licensed private social agency assisting the individual to resolve the issue.
Cooperation in establishing paternity or securing support is reasonably expected to result in:
Physical or emotional harm to the child; or
Physical or emotional harm to the parent or specified/caretaker relative that reduces the capacity to care adequately for the child.
The source of physical or emotional harm may be from individuals other than the absent parent.
Evidence includes: Medical records or written statements from a mental health professional indicating emotional health history, current emotional health, or diagnosis or prognosis concerning the emotional health of the child or caretaker relative. Other records such as court, medical, police, child protective services, DCFS, or ORS/CSS records, which indicate that the absent parent might inflict physical or emotional harm on the child or caretaker relative, or has done so in the past.
Emotional harm is defined as an emotional impairment that substantially affects the individual's functioning.
When the claim is based in whole or in part on anticipated emotional harm, consider the present emotional health and history, the intensity and probable duration of the emotional impairment, the degree of cooperation required, and the extent of involvement of the child in the paternity or support activity to be taken. Document these considerations.
Determining Good Cause for Not Cooperating
The supervisor will make the good cause determination based on:
Information contained in any Department of Workforce Services, Department of Health or Department of Human Services records.
Evidence supplied by the applicant or recipient, or
Investigation of the information provided, or
A combination of both evidence and investigation.
Acceptable evidence
The applicant/recipient must provide supporting evidence within TWENTY DAYS from the day the claim was made. An extension may be granted by the supervisor. Document the extension.
Acceptable evidence to support the good cause claim is listed above. If the applicant or recipient cannot provide supporting evidence, accept sworn statements from persons with knowledge of the circumstances which verify the good cause claim. Such statements need not establish whether abuse has occurred or been threatened, but must support the claimant's credibility. The supervisor will determine if the client has established good cause for not cooperating.
Investigation of Evidence
If evidence is not available or if evidence other than what is listed above is presented,the supervisor will investigate the circumstances of the good cause claim. When an investigation is made, any reasonable evidence easily accessible to the agency (i.e. Department of Human Services/DCFS records) may be used as the basis for a determination.
Do not release information from DCFS records to individuals outside of the Department of Workforce Services, the Department of Health or Department of Human Services.
DO NOT give information to the absent parent that could jeopardize the child or the specified/caretaker relative.
Contact with the absent parent might be necessary to establish good cause. Before such a contact is made, the client must be notified of the contact and respond by:
permitting the contact
presenting additional evidence so that the contact becomes unnecessary, or
cagreeing to a denial of the good cause claim, or
withdrawing the application or closing the case.
Enforcement Without Cooperation
The supervisor may determine that there is good cause for not cooperating but that ORS/CSS could proceed with Medical Support Enforcement WITHOUT THE COOPERATION OF THE RECIPIENT and it would not result in harm to the child or to the caretaker relative. Record the basis for the decision in the case file.
Before ORS/CSS may proceed with Medical Support Enforcement, a notice must be sent informing the applicant/recipient that ORS/CSS will proceed with Medical Support Enforcement activities without his or her cooperation. Once the notice has been sent, the recipient has 10 days to:
Agree that Medical Support Enforcement activities can continue without the participation of the recipient.
Present additional evidence that supports the claim that Medical Support Enforcement activities without their cooperation would pose a risk to the child or caretaker relative, OR
Withdraw the application, or request that the medical assistance case be closed.
If the recipient fails to respond within 10 days, close the case for failure to provide information. If the 10th day is a Non-business Day, the client has until the Business Day following the 10th day to respond.
If the recipient requests the medical assistance case closed, close the case accordingly.