Clients must receive written notice of decisions affecting their case. The purpose of the notice is to give clients information about their eligibility and to allow adequate time and information to contest decisions. This section includes information on the type of eligibility actions that require written notice, the content of notices, and timing of notices.
Processing Delays – Agency Delay.
Processing Delays – Applicant’s Failure to Provide Information.
Closings and Reductions in Eligibility and Benefits.
Increased Eligibility and Benefits.
Send clients written notice of:
l Approvals.
l Processing delays.
l Denials.
l Closings.
l Benefit changes.
Most notices are system generated for Minnesota Health Care Programs (MHCP). MMIS sends MinnesotaCare notices. The MMIS User Manual includes extensive information about MinnesotaCare (MCRE) notices, notice texts, and notices reports. MMIS also sends Minnesota Family Planning Program (MFPP) notices.
MAXIS sends notices for MA and GAMC. See MAXIS POLI/TEMP for information about notices generated by MAXIS.
Notices must include the following information:
l Action taken.
l Which household members the action affects.
l Effective date of the action.
l The reason for the action.
l The legal authority for the action.
l The right to appeal.
l Instructions for filing an appeal, including:
n Clients may represent themselves or use legal counsel, a relative, friend or other spokesperson.
n The conditions under which a client may continue to get assistance pending the outcome of the appeal.
n The right to re-apply for eligibility or additional eligibility.
n The requirement to repay assistance received while an appeal is pending if the agency wins the appeal.
Note: Spenddown cases have additional notice requirements. See Medical Spenddowns; Notices.
Usually, a 10-day advance notice must be sent when taking an adverse action. Adverse actions include:
n Denying coverage.
n Closing coverage.
n Reducing eligibility. (For example, increasing a premium or a spenddown.)
n Reducing covered services. (For example, switching an enrollee to a lesser MinnesotaCare benefit set.)
Note: When a change in an eligibility factor is known in advance, such as the client turning age 21, or increased hours or wages, the notice may be sent earlier to allow more time to resolve any issue or questions.
See the MMIS User Manual, MAXIS POLI/TEMP or the TSS Systems Availability Production Calendar in DHS-SIR for information on the timing of MMIS and MAXIS 10-day notices.
Ten-day advance notice is not required before denying coverage, closing coverage, reducing eligibility, or reducing covered services if there is probable fraud. In that situation, take the appropriate steps so written notice is mailed at least five days before the effective date of the action if:
n Facts indicate the action should be taken because of probable fraud by the enrollee, and
n All facts have been verified, if possible, through secondary sources.
In some situations, a 10-day advance notice is not required before denying coverage, closing coverage, reducing eligibility, or reducing benefits. Instead, take appropriate steps so the notice of adverse action is mailed no later than the effective date of the action. See below for specific situations that only require adequate notice.
In some situations, neither advance nor adequate notice is required before closing coverage, reducing eligibility, or reducing covered services. Instead, take appropriate steps so a written notice is mailed the next available business day. See below for specific situations that only require retroactive notice.
Advance and Adequate Notice When Enrollee is in Managed Care
If advance or adequate notice is sent before the capitation date, close coverage, reduce eligibility, or reduce covered services effective the next month. However, if the advance or adequate notice is sent after the capitation date, close coverage, reduce eligibility, or reduce covered services effective the month after the next month. See TSS Systems Availability Production Calendar on DHS-SIR.
Send a notice when eligibility is approved.
l MinnesotaCare:
n When a MCRE application is approved and in a pending awaiting payment status, the initial premium notice is also the approval notice.
n The notice explains that coverage will begin the first of the month after the household pays the initial premium.
n MMIS will deny coverage if the household fails to pay the initial premium within four months.
l MA/GAMC:
n MAXIS sends each requesting household member an approval notice when MA or GAMC eligibility is approved.
n The notices include appropriate reasons and authority.
Note: Program renewal dates may vary on MAXIS for an MA or GAMC enrollee who also receives cash assistance or Food Support. When using the information on the cash or Food Support renewal to renew MA or GAMC before the MA or GAMC renewal date, add worker comments to the system-generated cash or Food Support approval notice or use SPEC/MEMO to inform the enrollee that health care was renewed.
Processing Delays - Agency Delays
Send a notice when there is an agency delay in processing an application by the end of the application processing period due to circumstances unrelated to the applicant’s failure to provide information.
l Send a notice of the processing delay no later than the end of the processing period.
l Document the reason for the processing delay in case notes.
Note: Help the applicant obtain the information if the reason for the delay is the applicant’s inability to obtain information. Do not deny the case if the applicant is cooperating.
Send a notice if the application cannot be processed within 30 days of the date of application.
MMIS generates a person-based notice for MinnesotaCare for two situations when eligibility is pending:
n Pending Awaiting Payment.
Eligibility is set to pending awaiting payment when the client is eligible for MinnesotaCare. The notice generated by this action informs the client of the premium amount and that the household has four months from the date the case is pended to make the first payment.
n Pending but incomplete.
A client who has not provided information or verifications to determine eligibility is determined pending, but the application process is incomplete. The notice generated by this action informs the client that more information is needed to process the MinnesotaCare application and lists the items that are needed.
See Pending an Application for additional information about pending a MinnesotaCare case.
MAXIS will send the notice of the processing delay 10 days before the end of the processing period. See pending an application for additional information about pending an application or health care request on MAXIS.
In addition to the MAXIS generated pending notice, send the following information to the applicant. Use the SPEC/MEMO function in MAXIS or send a Minnesota Health Care Programs Request for Information (DHS-3271):
n Why the application is not yet processed.
n What the client must do (if anything) to complete the process.
n A statement that applicants must report any changes that have occurred since the date of application.
Processing Delays - Applicant's Failure to Provide Information
Send a notice when an application cannot be processed by the end of the processing period due to the applicant’s failure to provide information.
Give the applicant until the end of the processing period or 10 days, whichever is later, to provide the information.
Document the reason for the processing delay in case notes
Note: Help the applicant obtain the information if the reason for the delay is the applicant’s inability to obtain information. Do not deny the case if the applicant is cooperating.
Send a notice if the application cannot be processed within 30 days of the date of application.
MMIS generates a person-based notice for MinnesotaCare for two situations when eligibility is pending:
n Pending Awaiting Payment.
Eligibility is set to pending awaiting payment when the client is eligible for MinnesotaCare. The notice generated by this action informs the client of the premium amount and that the household has four months from the date the case is pended to make the first payment.
n Pending but incomplete.
A client who has not provided information or verifications to determine eligibility is determined pending, but the application process is incomplete. The notice generated by this action informs the client that more information is needed to process the MinnesotaCare application and lists the items that are needed.
If the application is still pending or incomplete on the next billing, MMIS will generate another notice to inform the applicant that the household must submit missing information within 30 days.
MMIS will generate a notice of denial listing the reasons coded on RIND if the client is pending at the second billing.
MAXIS sends a pending notice 10 days before the end of the processing period directing the applicant to provide information by the end of the processing period. The notice says the agency will deny the application unless the applicant provides information within 10 days of the date of the notice.
Using the SPEC/MEMO function in MAXIS or a Minnesota Health Care Programs Request for Information (DHS-3271), send the following information to the applicant if a request for all information and verification has not previously been sent:
n Exactly what missing information or verifications are needed.
n What the client must do (if anything) to complete the process.
n A statement that applicants must report any changes that have occurred since the date of application.
Deny the application if the applicant does not provide the requested information by the due date. Use the HC ELIG function in MAXIS to deny the application. The MAXIS denial notice explains that the applicant has an additional 10 days from the date of the notice to provide information. See POLI/TEMP for information on MAXIS notices.
Applicants must receive 10-day advance notice of a denial.
MMIS sends a denial notice when:
n An applicant is not eligible for coverage. The notice includes all the reasons (from RELG and RIND) for ineligibility.
n A household fails to pay the initial premium within four months of receiving the initial premium notice.
n A household fails to submit required information within 30 days of the date of the second pending notice requesting the information.
MAXIS generates a denial notice for each applicant and household member who is not eligible for MA or GAMC based on the action taken in HC ELIG. The notice generated by MAXIS gives the client 10 days from the date of the notice to provide information. Denial notices are generally mailed nightly. For MAXIS information, see TSS Systems Availability Production Calendar on DHS-SIR.
Closings and Reductions in Eligibility and Benefits
Send a 10-day advance notice before closing coverage, reducing eligibility, or reducing benefits.
Provide 10-day advance notice when an MHCP enrollee completes a Combined Application Form (CAF) as an application for a new program, the ongoing program is not due for renewal, and the information on the CAF indicates that the enrollee is no longer eligible for MHCP.
Example:
Alex receives GAMC. His next renewal is due for May. On February 23, he submits a CAF to apply for Food Support. The information on the CAF indicates he no longer qualifies for GAMC. Because the GAMC renewal is not due, Alex must receive 10-day advance notice of closure.
Action:
Approve the closure of GAMC on MAXIS at least 10 days prior to the effective date of April 1.
MMIS generates a cancellation notice when coverage has been canceled on a MinnesotaCare Case. The notice is generated either by cancellation codes entered on RIND in MMIS or by system-generated actions. See the MMIS User Manual for more information about MMIS notices.
MAXIS generates a closing notice for each applicant and household member who is not eligible for MA or GAMC based on action taken in HC ELIG. Closing notices are generally mailed nightly. See TSS Systems Availability Production Calendar on DHS-SIR.
See the MMIS User Manual and POLI TEMP for information on the timing of MMIS and MAXIS ten-day notices.
Sometimes a 10-day advance notice is not required before denying coverage, closing coverage, reducing eligibility, or reducing benefits. Send adequate notice in the following situations:
l The client sends a written and signed statement clearly indicating that the client wants coverage closed. However, if the client requests cancellation orally and does not submit a written statement, send ten-day notice.
Note: If a managed care capitation payment has already been made for the next month, coverage can only be closed for the first of the next available month.
l The client is eligible for another Minnesota Health Care Program with better benefits or less cost-sharing.
l The client is eligible for Medicaid (MA) in another state for the same period.
l The client’s whereabouts are unknown. The client’s whereabouts are unknown if mail sent to the client is returned as undeliverable and there is no information available on an alternate way to contact the client.
Example:
Joe’s mail is returned as undeliverable. Joe’s worker calls his cell phone and learns his home was foreclosed and he is temporarily living with a friend.
Action:
Do not close Joe’s case for whereabouts unknown because there is an alternate way to contact Joe.
In addition to the above exceptions, ten-day advance notice is not required for MA and GAMC in the following situations. Send notice no later than the effective date of the action.
n A household submits a signed Household Report Form (HRF) (or a signed renewal form at renewal) with information requiring a change that can be determined solely from the HRF or the renewal form.
Example:
Boris's six-month income renewal is due before October 1. He submits his HRF with all pay stubs attached on September 25. The HRF and pay stubs show that Boris will not be able to meet a spenddown for the next certification period. Send notice of termination effective October 1 for failure to meet a spenddown. Mail the notice on or before October 1.
Note: Ten-day notice is required if the enrollee completes an application for a new program and the active program is not due for renewal.
n A household provides information in writing other than on a HRF or renewal form and acknowledges in writing that the result will be reduction or closure. The enrollee must sign this written statement.
n A client enters an institution where clients are no longer eligible for MA.
n A client chooses to receive MinnesotaCare instead of MA or GAMC and pays the required premium. MMIS shows active MinnesotaCare statuses when clients have paid the premiums.
Notices of denial, closing, reduction of eligibility, or reduction of services may be sent after the effective dates of the action in the following situations:
l When a case opening must be delayed until after the end of an eligibility period, such as after a six-month spenddown period.
Example:
Rhoda applies for MA using a disabled basis on October 31. She requests retroactive coverage to July 1. She submits all required information on December 27. The worker processes the application on January 3 and determines that Rhoda met a six-month spenddown on July 17. Her six-month eligibility period ended December 31.
Action:
Open and close the case at the same time. Rhoda will receive both approval and closing notices.
l When an LTC spenddown must be adjusted for past months to reflect actual income or deductions.
Note: A waiver obligation can be adjusted retroactively but it cannot be retroactively adjusted on MMIS.
l When the spenddown type changes from a medical spenddown to an LTC spenddown.
l When a client's death has been verified.
l When an applicant requests retroactive MA and is denied coverage for the retroactive months, a retroactive denial may be sent.
Increased Eligibility and Benefits
Send notices of increased eligibility or benefits, such as reduced spenddown or other cost-sharing, before the effective date of the action whenever possible. Clients are eligible for the increased eligibility and benefits regardless of whether they receive advance notices.
See Appeal Decisions for information on notice requirements following an appeal.