M1500 Notices

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M1500 Notices

EqualityCare Eligibility Manual > M1500 Notices

Purpose: This section will provide information on the information to be included in Notices generated through EPICS, and the time frames in which they should be provided.

Current Policy Effective Date: October 1, 2006

Date Last Reviewed: July 5, 2007

Previous Policy:

POL M1500: NOTICES

1. Notices Must Contain Specific Information

All notices must contain the following information:

· The action or intended action to be taken.

· The amount of the benefit to be issued, as appropriate.

· The date the action will occur.

· The reason and specific regulation(s) supporting the action.

· A description of the actions, if any, the assistance unit must take to avoid the adverse action.

· A statement of the person’s right to request an informal conference at a DFS Field Office or outstationing facility, and to request an administrative hearing.

· The explanation of the recipient’s obligation and responsibility to report to the DFS Field Office changes in income, resources, living situation, school attendance, and child care provider.

· The beginning and ending dates of a certification period.

2. Notices of Approval Must Contain Specific Information

The following information must be included in a notification of approval of an application:

· Variations in benefit levels within the certification period, if any.

· An explanation of the difference in initial month benefits and subsequent benefits, when appropriate.

3. Reason For Denial Must Be Included on Notice

Include the reason for a denial of an application and what the assistance unit must do to reapply or reactivate the application.

4. Notices of Pending Application Must Include Specific Information

Include the following information in a notification of a pending application because of the fault of DFS:

· Notify the assistance unit with an application pending at the end of the first 30 days of the following:

o That the application is pending.

o That the assistance unit may be eligible for benefits back to the date of application.

· Notify the assistance unit with an application pending at the end of 60 days when the case does not contain adequate information to make an eligibility determination of the following:

o That the case is being denied.

o That the assistance unit may reapply.

· Notify the applicant for Medicaid (HCBS) if the application is pending until a plan of care is approved.

5. Notice of Approval or Denial Must Be Mailed Within 45 Days

6. 10-Day Notice of Adverse Action Must Be Provided

The client must be provided a 10-Day Notice of adverse action prior to their benefits being terminated or reduced.

Allow an adequate notice of adverse action under the following circumstances:

· Applicant/recipient dies.

· Application is made in another state.

· Client requests closure.

Reference:

Defining Requirement 42 CFR 431.213

42 CFR 435.912

42 CFR 435.916

42 CFR 431, Subpart E

Social Security Act, Title XIX

Clarifying Information:

1. A Notice is defined as a notice of action for all programs which is mailed to an assistance unit for notification of action on an application and any adverse action.

Training Link: Not available at this time.

Worker Responsibilities:

Sending Notices

1. Mail the assistance unit a notification of approval or denial within 45 days from the date of application.

2. Do Not require a new application if the assistance unit takes the appropriate action within 45 days of the initial application.

3. Notify the client of the reason if a delay in the eligibility determination occurs and approve or deny the case within 60 days from the date of application.

4. Mail the assistance unit a 10-Day notice of adverse action prior to terminating or reducing the benefit.

5. Notify the applicant for Medicaid (HCBS) immediately when determined eligible and the application is pending until a plan of care is approved.

6. Refer to Medicaid Table 16 for a list of EPICS Medical Related Computer Notices