CHIP Policy

803 Notification

Effective Date: January 1, 2014

Previous Policy

 

Notice Requirements

The agency must provide all applicants and recipients with a written notice of:

• the decision on an application or review;
• any action to terminate, discontinue, or suspend an individual's medical assistance;
• any action that changes the form or amount of benefits;
• any request for information or verification needed to determine eligibility.  

1. Notice to Approve or Increase Benefits

The eligibility agency must notify an individual whenever it approves the individual's application or renews the individual's eligibility at review for medical assistance benefits.  The agency must notify the individual of any positive action affecting the form or amount of the individual's benefits, such as a change from Plan C to Plan B.      

A notice to approve or renew eligibility or increase benefits must include the following information:

1. What action the agency is taking, i.e., approval of an application or review or a change to a different medical program that allows an member to receive more medical services.
2. Who the action affects, and any differences in how each person is affected.  If an action affects everyone in the household in the same way, the notice does not have to name each person separately or explain the effect more than once.
3. The date such action is effective.

A notice to approve or renew eligibility or improve benefits does not require 10-day advance notice. The notice of a positive change can be sent after the effective date, but should be sent as soon as possible upon making a change.

2. Adverse Action Notices

1. The eligibility agency must notify the individual of an adverse action taken on an application or eligibility review, including a change from Plan B to Plan C.
2. Most adverse actions require 10-day advance notice before the date of the adverse action.
3. The agency must send the notice to a mailing address agreed upon by the individual or the individual’s representative.
4. An individual can request to get copies of notices at the local office or electronically (MyCase).
5. An adverse action notice must include the following information:
   1. What action the agency is taking, i.e., denial of an application; change to a different CHIP plan; termination of eligibility.
   2. Who the action affects and any differences in how each person is affected.  If an action affects everyone in the household in the same way, the notice does not have to name each person separately or explain the effect more than once.
   3. The date such action is effective.
   4. The reason for the action.
   5. The basis of the verification for MAGI programs.
   6. The policy citation or the federal or state regulation that supports the action.
   7. An explanation of the individual's right to a fair hearing.

3. Exceptions to 10-day Advance Notice

Negative action can be taken without giving the recipient 10-day advance notice in the following situations:

1. The recipient requests in writing that his case be closed.
2. The recipient has been admitted to an institution under governmental administrative supervision.
3. The recipient’s whereabouts are unknown and the post office returns mail indicating no forwarding address.
4. The local office has determined the recipient is receiving assistance in another state.
5. The local office has factual information confirming the death of a recipient. In this instance, the notice must be mailed on the date the case closure is recorded in the case record. The effective date of the closure is the date the person died.
6. The recipient has moved out of Utah and is not expected to return.
7. The recipient is eligible for Medicaid.

4. Five Day Advance Notice for Suspected Intentional Program Violation

If the facts indicate that there has been an intentional program violation by the recipient, send the notice of adverse action at least 5 days before the effective date of action.

5. Requesting Information or Verification

When the eligibility agency needs forms, information or verification from the individual to determine eligibility, the agency must send a written request to the individual.

1. The request must say what is required and the due date for providing the requested information, form or verification.
2. The agency must allow the individual at least 10 days from the date on the notice to respond.
3. The notice must tell the individual he may ask for more time to respond and may ask the agency to help obtain information or verification if the individual cannot get it.

For policy about verifications, see sections 701 (applications), 704 (reviews), 705 (verifications), and 804 (changes).

6. Proper Notice for Renewals

1. When members do not complete renewals, the agency gives 10-day notice for closure.
2. If the member contacts the agency before the end of the review month, benefits must be restored for the following month if there is a request for additional verification or workload prevents workers from re-determining eligibility timely.
3. If the eligibility agency makes an adverse decision before the end of the review month, take the negative action in the first month for which proper notice can be given. Use of Electronic Notices
4. The eligibility agency must give applicants and recipients the option to receive notices and information through an electronic format.
   1. Confirm by regular mail the individual’s choice to receive electronic notices.
   2. The individual may choose to receive notices through regular mail at any time.
5. Electronic notices must be posted to the recipient’s account within 1 business day.
   1. Send an email or other electronic communication to alert the member that a notice has been posted.
6. If the electronic notice is not transmitted successfully, send the notice by regular mail 3 days from the failed electronic notice date.
7. At the member’s request, the eligibility agency must provide any notice by regular mail that had previously been posted electronically.

Informing Individuals of Hearing Rights

1. The eligibility agency must inform individuals of the right to ask for a fair hearing if the individual disagrees with an agency action, or does not make a timely decision on an application.
2. Individuals must be informed at application and any time the eligibility agency takes an action affecting the individual's eligibility.
3. The notices sent to individuals must explain:
   1. how the individual can ask for a hearing,
   2. how long the individual has to ask for a hearing,
   3. how a recipient may receive continued benefits while the hearing takes place (See 120-5), and
   4. how the individual may represent himself, or have a family member, friend, representative or attorney represent him.