(Revised 1/1/09 ML #3173)
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Purpose: The applicant must be informed in writing of the reason(s) for a denial or termination of service or program.
Before the SFN 1647 is sent to a client, the HCBS Case Manager must contact the HCBS Program Administrator responsible for SPED, Ex-SPED and Medicaid Waiver closings via email to obtain the appropriate citation to use in the “As set Forth” section of the form. The legal reference must be from state or federal law and/or Administrative Code, citing policy and procedure manual references is not sufficient.
The email must include the clients name, funding source (i.e. SPED, Ex-SPED, Medicaid Waivers) and the reason you are reducing, closing, or terminating services. You do not need to send a copy of the completed SFN 1647 to the State office.
The county may send a cover letter with the Notice identifying other public and/or private service providers or agencies that may be able to meet the applicant's needs.
When the client is no longer eligible for a specific HCBS Program or service, the county must terminate services under the funding source and cancel any current “HCBS Authorization to Provide Services,” SFN 1699, issued to the client’s providers. Even if services continue under another funding source, the client must be informed in writing of the reasons he/she is no longer eligible for the program using the SFN 1647 form.
Date: Record the date of completion;
Denial, Termination, or Reduction, Checkbox: Check the appropriate box whether it is a denial of a requested service or program; or termination of an existing service or program; or reduction of an existing service.
Client Name, Client ID: Record the individual’s first and last name and the identification number (if applicable);
County Employee Name, County Name, Title of Employee: Self Explanatory;
“It has been determined...program or service”: Indicate the service(s) or program(s) being denied, terminated, or reduced.
“Reason”: Record the reason why the individual is being terminated for service or program or the reason for denial or the reason for a reduction in existing services.
“As Set Forth”: Record the state or federal legal reference supporting the reason for denial, termination, or reduction in service that you received from the Program Administrator.
Date This Denial….is Effective: The client must be notified in writing at least 10 days prior to the date of termination, denial, or reduction of a service or program. The date entered on the line is 10-calendar days from the date of mailing the Notice or the next working day if it is a Saturday, Sunday, or legal holiday.
If a Medicaid appeal is received before the date of termination above is effective, services can continue until a hearing decision has been made. If the department's decision is upheld the individual will be required to reimburse for services provided after the termination date.
If a SPED or ExSPED appeal is received before the date of termination above is effective, services and payment for the services can continue only until the date of termination above is effective.
This form is not available through the State Office. It is available through the State e-form system. Click here to view and/or print this form.