1430 Written Change of Case Action

1430 Written Notice of Case Action

An applicant or recipient of assistance shall be notified promptly of the action taken on his case. The recipient of assistance shall also be notified of other changes such as an increase or decrease in the amount of the spenddown, cost share, suspension, or reinstatement after suspension.

A notice of action shall be sent promptly to the applicant or recipient with a copy of any manually prepared notices filed in the case record. When appropriate, a copy must be made available on approvals, suspensions or closure to HCBS care coordinator. Specialized notice forms are required for all cases involving a spenddown, and for all cases in which the medical program will assume at least partial payment for care situations.

Notices shall indicate clearly the action taken, the effective date, and such other information as the situation may require.  For all approvals, notice must include the beginning and ending dates of the review period.  If an application is denied, the applicant shall be informed of the basis for this action.  A similar procedure shall be followed for all other changes.

1431 Timely and Adequate Notice

The agency shall give timely and adequate notice of agency actions to terminate, suspend, or reduce assistance except as provided for in 1432 regarding dispensing with timely notice and in 1434 regarding negative actions resulting from information obtained through federal match data. See 9340 for further information on notice provisions for reviews.

1. Adequate Notice - Adequate means a written notice that includes a statement of what action the agency is taking, the reasons for the intended agency action, the specific manual references supporting such action, an explanation of the individual's right to request a fair hearing, and the circumstances under which assistance may be continued if a fair hearing request is made. All notices must be adequate. 
2. Timely Notice - Timely means that the notice is mailed at least 10 clear days before the effective date of action.  Neither the effective date of action nor the mailing date shall be considered in determining this 10 day period.  For closures, the consumer must receive the notice prior to the last day of eligibility.  For increases in premium or liability, the consumer must receive the notice prior to the 1st of the month for which the change is effective. The Processing Deadline Code Card Chart on the KEES Repository shall be used to identify the last day in which action can be taken in order for timely notice to be provided for the various scenarios.

An increase in an unmet spenddown does not require timely notice; however a change which results in the spenddown changing from met to unmet does require timely notice.  When a spenddown for a base period changes from met to unmet, the consumer is notified both by the Clearinghouse and by MMIS.  The MMIS notification must be received before the 1st day they return to having an unmet spenddown.

1432 Adequate Notice Only

When only adequate notice is required, such notice may be received by the household at the time reduced benefits are received or if benefits are terminated, at the time benefits would have been received if they had not been terminated. The agency is not required to send timely notice but must send adequate notice not later than the date of action when:

1. The agency denies an application for assistance. However, denials resulting from information obtained through federal match data shall be subject to the provisions of 1434.
2. The agency has factual information confirming the death of a client or of the payee when there is no relative available to serve as new payee.
3. The agency receives a clear written statement signed by a client indicating that he no longer wishes assistance, or that gives information which requires termination or reduction of assistance, and the client has indicated, in writing, that he understands that this must be the consequence of supplying such information.  
4. The client has been admitted to an institution and further medical assistance will not be provided to that individual.
5. The client has been placed in a Medicaid approved institution for long term care or begins HCBS and will receive Medicaid payment for the cost of care.
6. The client's whereabouts are unknown and agency mail directed to him has been returned by the post office indicating no known forwarding address. The procedures of 9124 must be followed to terminate assistance when the client's whereabouts are unknown.
7. A client has been accepted for assistance in a new jurisdiction and that fact has been established by the jurisdiction previously providing assistance. 
8. Reserved
9. Assistance is approved and negative case action such as a closure or grant reduction is incorporated into the initial notice of action to the client. However, negative action resulting from information obtained through federal match data shall be subject to the provisions of 1434.  
10. Reserved
11. A client is disqualified for fraud through a court of appropriate jurisdiction. 
12. Reserved
13. The client has been receiving increased benefits to restore lost benefits, the restoration is complete, and the household was previously notified in writing of when the increased benefits would terminate.
14. Reserved 
15. A client fails to respond to a written repayment agreement within 10-days of the date the notice is mailed and benefit reduction is invoked. See 11125 (3)(b).

1433 Automatic Benefit Adjustments for Classes of Clients

When changes in either state or federal law require automatic adjustment for classes of clients, timely notice of such adjustments shall be given which shall be adequate if it includes a statement of the intended action, the reasons for such intended action, a statement of the specific change in the law requiring such action, and a statement of the circumstances under which a hearing may be obtained and assistance continued.

1434 Notice of Actions Resulting from Federal Match Data

Based on the provisions of the Computer Matching and Privacy Protection Act, no immediate action to suspend, terminate, reduce, or deny assistance may be taken as a result of information obtained through federal match data which has not been determined to be accurate and reliable by the federal agency producing the data. When the federal information has not been determined to be accurate and reliable, the individual must be given 30 days from the date the notice of action is received to verify or contest the match data. This means that such notice must be sent at least 35 days prior to the effective date of action for recipients or the date the application is to be processed for applicants.

Federal matches currently affected by these provisions include the PARIS, SIEVS (IRS and BEER data) match, VA match, and matches identified via the eDRS. It does not include BENDEX, SDX, SAVE information from INS, and third-party queries obtained through SSA as all of these data exchanges are either considered to be accurate and reliable or involve a computer match process between state and federal records. It also does not include Employment Security matches as this is not a direct federal-state match.

If the individual does not respond to the notice, final action based upon the match data can be taken upon expiration of the 35-day notice period and allowing for timely and adequate notice of action. All or part of the 10-day timely notice period may run concurrently with the 35-day notice period. However, all BEERS and IRS-related match data is to be considered as a lead only and not to be used as primary verification or evidence without further independent verification.

If the individual confirms the validity of the information prior to the expiration of the 35-day period, action can be taken immediately allowing for 10 day timely and adequate notice. In addition, for applicants, action can be taken to deny the application without a 35-day notice period, if the individual has already confirmed the match data through verification provided or information which was incorporated on the application form.

If the individual contests the data during the 35-day notice period, no action can be taken until the information is further verified. If the individual cannot provide verification in regard to IRS or BEER data, contact with such sources as the financial institution, employer, etc. will need to be made.

Client cooperation in the verification process will be essential for any action prior to the 35-day notice period. If the client refuses to cooperate and/or contests the information and verification cannot be otherwise obtained, action can be taken on the case following the expiration of the 35-day notice period and allowing for timely and adequate notice of the action.