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Effective: December 1, 2006 |
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26ar1 - Notices (Archive) |
Archived: February 1, 2009 |
Notify clients of:
l Approvals.
l Denials.
l Delays.
l Terminations.
l Reinstatements.
l Benefit changes.
Notices are automated for all of the health care programs. MMIS sends MinnesotaCare notices. See the MMIS User Manual section on MinnesotaCare notices for detailed information. The MMIS User Manual includes extensive information about MinnesotaCare (MCRE) notices, notice texts, and notices reports.
MAXIS sends notices for MA and GAMC.
Closing and Benefit Reductions.
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 and instructions for filing an appeal.
l The conditions under which a client may continue to get assistance pending the outcome of the appeal.
l The requirement to repay assistance received while an appeal is pending if the agency wins the appeal.
l MinnesotaCare:
n When you approve a MCRE application 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 If the household fails to pay the initial premium within four months, MMIS will deny coverage.
l MA/GAMC:
n MAXIS sends each household member an approval notice of initial eligibility for an application or for continued eligibility for a renewal.
n The notices include appropriate reasons and authority.
l MinnesotaCare:
Send a notice of delay whenever there is a processing delay of 30 days or more.
MMIS generates a notice when an application is pending but incomplete. The notice lists all information the applicant needs to supply to complete the application.
If the application is still pending/incomplete on the next billing, MMIS sends another notice to inform the applicant that the application will be denied unless the applicant supplies the information within 30 days.
l MA/GAMC Pending Notices:
n Pending notices notify clients when the processing time will be longer than the time allowed in Application Processing.
The pending notice must include this additional information:
m Whether the delay was caused by the agency or the client.
m A statement that applicants must report any changes in circumstances since the date of application.
If the client needs further explanation, add worker comments to the pending MAXIS notice. Workers may also use SPEC/MEMO function in MAXIS to explain the action. Include:
q The exact cause of the processing delay.
q What the client must do (if anything) to complete the process.
n If the agency causes the delay, MAXIS will send the notice by the end of the processing period.
n If the delay is the result of the household's failure to provide information, MAXIS will send the notice 10 days before the end of the processing period. MA and GAMC applicants must receive 10-day advance notice of intent to deny the application for failure to complete the application process.
l MinnesotaCare:
MMIS sends a denial notice when:
n An applicant is not eligible for coverage. The notice includes all the reasons (from 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.
l MA/GAMC:
n MAXIS generates a denial notice for each applicant and household member who is not eligible for MA or GAMC.
If MAXIS has sent the pending notice and the 10-day advance notice of intent to deny, MAXIS sends another denial notice at the end of the processing period. See Processing Delays.
n If an applicant receives a pending notice and then the agency finds that the applicant is not eligible for any reason, including failure to provide information after receiving 10-day advance denial notice, MAXIS sends a denial notice.
Closings and Benefit Reductions
Send notice when:
l Coverage is ending for one or more household members.
l Covered services are reduced, such as changing to a lesser MinnesotaCare benefit set.
l The enrollee will have increased cost sharing, such as increased premium or spenddown amount.
Most of these actions require ten-day advance notice. See the MMIS User Manual and POLI TEMP for information on the timing of MMIS and MAXIS ten-day notices.
Ten-day notices are not required for these situations:
l You have information confirming the death of a client.
l You receive a written and signed statement from the client clearly indicating that the client wants coverage closed.
Note: If the client requests cancellation orally and does not submit a written statement, send ten-day notice.
l The client is eligible for another Minnesota Health Care Program with better benefits and/or less cost sharing.
l The client is eligible for Medicaid (MA) in another state.
If services are received through a managed care plan and you are acting before the managed care capitation cutoff, close effective the first of the next month.
If you are acting after DHS has paid the managed care capitation for the next month, close eligibility effective the month after the next month. See MAXIS and MMIS Cutoff Calendar in CountyLink.
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 HRF (or a signed renewal form at renewal) with information requiring a change that you can determine solely from the HRF or the renewal form.
Example:
Boris's 6-month income review 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 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 if the active program is not due for renewal.
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 now longer qualifies for GAMC. Because the GAMC renewal is not due, Alex must receive 10-day notice of closure. Send a closing notice effective April 1.
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.
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.
n The agency has verified probable fraud by the household that is the reason for the reduction or closure. Send notice at least five days before the effective date of the action.
You may send notices of denial, termination, or an increase in spenddown after the effective dates of the action in the following situations:
l When you must delay a case opening 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 termination notices.
l When you must increase or decrease a LTC continuing spenddown for past months to reflect actual income.
l When you change the spenddown type from a medical spenddown to an institutional spenddown.
l When you have verified the client's death.
Do not send additional notice when a client appeals an action and the human services referee upholds the agency action. The original notice and appeal decision are the client's notice.
Send notices of increased benefits, such as reduced spenddown or other cost-sharing, before the effective date of the action whenever possible. Clients are eligible for the increased benefits regardless of whether they receive advance notices.
When a court or DHS Appeals Office orders retroactive eligibility for a past period, send a notice.