Current through Register Vol. 49, No. 13, September 23, 2024
Subpart
1.
Notice to applicant or recipient.
The local agency or department shall send the person a
written notice, in the format prescribed by the department, when the agency or
department denies prior authorization, restricts free choice of provider, or
reduces services, or reduces, denies, or terminates the person's medical
assistance eligibility. The notice must clearly state the proposed action, the
reason for the action, the person's right to appeal the proposed action, and
the person's right to reapply for eligibility or additional eligibility. The
notice must comply with parts
9505.0100 and
9505.0140. Except as in subpart
2, the notice must be sent as
specified in items A to C:
A. In the
case of restriction of free choice of provider or reduction of services, the
notice must be sent by the department to the person no later than ten days
before the effective date of the restriction or reduction.
B. In the case of denial of prior
authorization, the department shall notify the recipient and the provider no
later than 30 working days after receipt of all information required for prior
authorization.
C. In the case of a
denial, reduction, or termination of eligibility, the local agency shall notify
the person no later than ten calendar days before the effective date of the
action. Except in the case of the recipient's death, the effective date of the
termination is the first day of the month after the month in which the
recipient no longer met the eligibility factors. In the case of a recipient's
death, the effective date of termination is the day after the date of the
recipient's death.
Subp.
2.
Exceptions to period of notice.
The circumstances in items A and B permit exceptions to the
period of notice required in subpart
1:
A. The period of notice may be five days
before the date of the proposed action if the local agency has facts indicating
probable fraud by the applicant or recipient and if the facts have been
verified through a secondary source.
B. The agency may mail a notice not later
than the date of action if:
(1) The local
agency has facts confirming the death of an applicant or recipient. The
effective date of the notice is the day after the date of death.
(2) The local agency receives a written
statement from the applicant or recipient that he or she no longer wants to
receive medical assistance.
(3) The
recipient has been admitted to a penal facility, or an institution for the
treatment of mental diseases where he or she is ineligible for further health
services.
(4) The local agency
verifies that another state has determined that the applicant or recipient is
eligible for medical assistance.
