Reductions, Denials, and Terminations 535-05-50

(Revised 4/1/12 ML #3326)

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An individual dissatisfied with a decision made regarding personal care services may appeal that decision to the Department of Human Services under the fair hearing rules set forth in N.D.A.C. 75-01-03-03. An individual must be informed of the right to appeal any actions by the case manager or the department that result in denial, suspension, reduction, discontinuance, or termination of personal care services. Refer to Service Chapter 449-08 for more information with regard to Hearings and Appeals.

Denial/Termination/Reduction

The applicant/client must be informed in writing of the reason(s) for the denial/termination/reduction.

The Notice of Denial/Termination/Reduction form (SFN 1647) is dated the date of the mailing. Contact the HCBS Program Administrator to obtain the legal reference required at “as set forth . . . ." The legal reference must be based on federal law, state law and/or administrative code; and may include a policy and procedures manual reference(s). The citation used to complete the SFN 1647 must be obtained from a HCBS Program Administrator or the Assistant Director of Medical Services.

The client must be notified in writing at least 10 days (it may be more) prior to the date of terminating or denying services (UNLESS it is for one of the reasons stated in this section that does not require a 10-day notice). The date entered on the line, the effective date field, is 10 calendar days from the date of mailing the Notice (SFN 1647) or the next working day if it is a Saturday, Sunday, or legal holiday.

Termination of a service is discontinuing the service. The client must be informed in writing of the Termination by providing the client with a completed SFN 1647 or the client may provide a written statement indicating they no longer want the service.
Denial of a service may include denying the service to a new applicant or denying the number of units a current client requests.

When denying units the client has requested, the client must be informed in writing of the Denial by providing the client a completed SFN 1647.

When a client contacts the HCBS Case Manager or DD Case Manager per phone for general information about the service, the applicant must be made aware that a formal determination of eligibility for the service cannot be made by phone. The client must be offered the option to complete an Application for Services SFN 1047. Upon receipt of the completed SFN 1047 a home visit would be scheduled to determine eligibility.

After the SFN 1047 is received and a formal assessment is completed the client must be informed in writing of the Denial by providing the client with a completed SFN 1647 or the client may provide a written statement indicating they do not want the service.

When a home visit is completed to assess or inform an applicant about services, an application for service is implied by the client and a completed SFN 1647 must be provided informing the client of the Denial or the client can provide a written statement indicating they do not want the service.

Reduction in services may include reducing the number of units or reducing the tasks in a specific category. A written reduction notice is required (the client agreeing with the reduction is not sufficient).

If the service is reduced the client must be informed in writing of the reason(s) for the reduction in service on the SFN 662, the effective date of the reduction must be no sooner than 11 days after the client signs the SFN 662 and the client must be given a copy of the appeal rights printed on back of the SFN 662.

Any of the reasons below do not require a 10-day notice:

The client enters a nursing home.
The county or Human Service Center has received in writing the client’s decision to terminate services.
Client’s whereabouts are unknown and attempt to contact the client are supported by documentation in the client's file.
State or federal government initiates a mass change which uniformly and similarly affects all similarly situated applicants, recipients, and households.
Case Management has factual information confirming the death of the client.

Termination of a Personal Care Service Plan (A Termination notice, SFN 1647, is required or the client can provide a written statement indicating they no longer want the service.)

Personal Care Service has not been used in 60 days:

The authorization for personal care service may be terminated if the service is not used within 60 days, or if services lapse for at least 60 days, after the issuance of the authorization to provide personal care services.

Health Welfare and Safety:

The department may deny or terminate personal care services when service to the client presents an immediate threat to the health or safety of the client, the provider of the service, or others, or when the services that are available are not adequate to prevent a threat to the health or safety of the client, the provider of services, or others.

The client is no longer eligible for Medicaid:

The Case Manager must send a letter informing the client that eligibility for MSP-PC is dependent on eligibility for Medicaid (the right to appeal the closure of the Medicaid benefit is sent to the client by Economic Assistance).