Decision and Notice 510-05-25-25

(Revised 01/03 ML #2833)

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(N.D.A.C. Section 75-02-02.1-03)

 

1. A decision as to eligibility will be made promptly on applications, within forty-five days, or within ninety days for individuals for which disability is pending, except in unusual circumstances. When these time periods are exceeded, the case must contain documentation to substantiate the delay.

Applications for disability-related Medicaid should be made to both the Social Security Administration and the county agency. When the Social Security Administration denies an application because of lack of disability the application for Medicaid must also be denied. The Social Security Administration's decision with regard to disability is binding. The Medicaid application should not be held pending an appeal of the Social Security decision.

2. Following a determination of eligibility or ineligibility, all applicants must be notified of either approval or denial of Medicaid.

The notice must address eligibility or ineligibility for each individual month requested including all prior months and through the processing month. In instances where Qualified Medicare Beneficiaries (QMB) or Special Low-Income Medicare Beneficiaries (SLMB) and another coverage is requested, a decision must be made on both types of coverage and the applicant must receive one notice including both determinations.

 

If an applicant is denied, or is ineligible for any of the prior months or the processing month, the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested.

3. Once a decision to deny eligibility is made on an application, a new application is needed to re-apply for assistance.

4. As specified below, a notice must be sent in all ongoing cases in which a proposed action adversely affects Medicaid eligibility.

1. A notice must be mailed at least ten days in advance of any action to terminate or reduce benefits. The date of action is the date the change becomes effective.

This "Ten-Day Advance Notice" must include the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested. This gives the recipient an opportunity to discuss the situation with the county agency, obtain further explanation or clarification of the proposed action, or present facts to show that the planned action is incorrect. The recipient may appear on his own behalf or be represented by legal counsel, a relative, a friend, or any other spokesperson of their choice.

2. A "Ten-Day Advance Notice" is not required when information exists confirming the death of a recipient.
3. Under the following circumstances a "Ten-Day Advance Notice" is not required; however, a notice containing the reason(s) for the intended action, the specific administrative code or manual reference supporting the action, the right to a fair hearing, and the circumstances under which assistance is continued if a hearing is requested, must be mailed no later than the date of action:

1. The recipient provides a signed, clearly written statement providing information that requires a termination or reduction in benefits, and the recipient indicates that he or she understands that benefits will be reduced or terminated;
2. The recipient provides a signed statement requesting termination of assistance (an oral request will also suffice if recorded in the casefile narrative and reflected on the adequate notice to terminate assistance. Termination may be effective as of the current date or a date in the future);
3. The recipient has been admitted to an institution where he or she is ineligible for further services;
4. The recipient's whereabouts are unknown and mail directed to the client is returned by the post office indicating no known forwarding address;
5. There is factual information that responsibility for providing assistance has been accepted by another state or jurisdiction; or
6. The recipient begins or ceases to receive care in a specialized facility, or nursing care services in a facility (LTC) or in the community (HCBS).

4. A "Ten-Day Advance Notice" is not required when probable fraud exists.

When the county agency obtains facts through objective collateral sources indicating the likely existence of fraud, an advance notice of proposed termination or reduction of benefits must be mailed only five days in advance of the date the action is to be taken. This shorter period allows for more prompt corrective action when probable fraud situations are uncovered.

5. Assistance may terminate at any time during the month. If, however, eligibility exists for at least one day of the month, eligibility generally exists for the entire month. Some exceptions to this rule are:

• The date of death is the ending day of eligibility;
• The last day of eligibility is the date of entry into a public institution; and
• The last day of eligibility for a recipient eligible as a caretaker relative is the date the last child in the Medicaid unit enters foster care or the date parental rights are terminated.

Reminder: When eligibility is terminated due to death, the eligibility of other individuals in the case cannot be reduced or terminated without appropriate notice. Likewise, when a caretaker relative is no longer eligible because the last child entered foster care, or parental rights were terminated, the caretaker relative’s eligibility cannot be ended without appropriate notice.

6. Assistance cannot be terminated as of a past date except in case of death or if another state has assumed responsibility for providing assistance and then only if no assistance has been paid by North Dakota for the period in question.

7. Errors made by public officials and delays caused by the actions of public officials do not create eligibility or additional benefits for an applicant or recipient who is adversely affected.