Decision and Notice 510-05-25-25

(Revised 1/1/18 ML #3508)

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

 

Applicants and recipients may choose the method by which they are notified of their eligibility status. They may choose paper, electronic, or through their portal account.

 

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, an applicant 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 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.

Section 1902 of the Social Security Act requires that Medicaid ID Cards and Health Care Coverage notices be made available to an eligible individual who does not reside in a permanent dwelling or does not have a fixed home or mailing address. To meet these federal regulations, when an individual applies for Health Care Coverage and does not have a residential or mailing address, or is unable to utilize a friend or relative’s address to receive their mailing, the County Social Service Office address must be used for the individual.

Example: Applicants Name

c/o XXXXX County Social Service Office

123 Main Street

Any town, ND 58111

When an individual applies for Health Care Coverage, and does not have an address to receive his/her mail, the individual must be informed of the following:

• The individual will be required to pick up their mail at the county office on a weekly basis; and
  
  
• Failure to pick up their mail for three (3) consecutive weeks may result in their Health Care Coverage being closed.

Since individuals who apply for Health Care Coverage are not required to complete a face to face interview:

• If the individual has a telephone contact number, the requirement to inform the individual will need to be done through a telephone call and this must be documented in the casefile.
  
  
• If the individual does not have a telephone contact number, all methods of informing the individual have been exhausted, and the individual does not stop by the county office for three (3) consecutive weeks, the case must be closed.

When an individual fails to pick up their mail for three (3) consecutive weeks and the individual has not contacted the county social service office, the case must be closed for the reason of ‘Loss of Contact/ Whereabouts Unknown’. Remember to document this in the casefile narrative.

Note: 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 effective date of the action.

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 (as described in subsection 5) 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 (as described in subsection 5) no later than the effective 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 (changes reported on the change report form, the TANF monthly report, the review form, or via an applicant's or recipient's known email address  meet this requirement);
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). Information reported via an applicant's or recipient's known email address is considered a signed statement for Medicaid;
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 has a change in the level of medical care prescribed by the individual's physician, such as the recipient begins or ceases to receive care in a specialized facility, an institution for mental diseases (IMD), a Psychiatric Residential Treatment Facility (PRTF), 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. System generated notices are dated and mailed on the next working day after they are approved in the eligibility system.  Consideration must be given to weekends and holidays (i.e. a notice approved on a Friday is dated and mailed the following Monday, however, if Monday is a holiday, the notice is dated and mailed on Tuesday. This may mean approving the notice 1 to 5 days prior to the effective date of action).

 

6. 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:

1. The date of death is the ending day of eligibility;
2. The last day of eligibility is the date of entry into a public institution

Reminder: When eligibility is terminated due to death, the eligibility of other individuals in the case cannot be reduced or terminated without appropriate notice.

 

7. 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.

 

8. 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.