(1/1/09 ML #3172)
Purpose: The applicant must be informed in writing of the reason(s) for a denial or termination of service.
The case manager 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 or ineligible for the Medicaid State Plan Personal Care Service Option, the case manager must terminate or deny services and inform in writing of the reason(s) for a reduction, denial, or termination of service. The case manager must also cancel any current “Authorization to Provide Personal Care Services,” SFN 663, 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.
If a client initials or checks the check box on the SFN 662 indicating that they are not in agreement with the plan and/or before providing a 10-day closure notice, you must send an email to the HCBS Program Administrator responsible to provide citations for MSP-PC.
The email must include the clients name, funding source (i.e. MSP-PC), 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.
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);
Case Manager Name, County or Human Service Center 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 you disagree with this decision, please contact the following: If Case Management other than County enter your supervisor’s name.
And to request a conference with the County Director or designee, contact the following: If Case Management other than County, enter your supervisor's name.
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.
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.