Transcript Decision Notices

Writing Good Decision
Notices
July 2010
Chris Ellis, SPD Hearing Representative
1
Objectives
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Outline the types of decision notices and the
elements required on each notice.
Understand the difference between an
adequate and inadequate notice.
Knowledge & tools to write a good decision
notice.
Provide resources and contact information.
2
What is a decision notice?
461-175-0010

A decision notice is a written notice of a
decision by the Department regarding an
individual's eligibility for benefits in a
program.
3
What Must a Decision Notice
Include? 461-175-0010
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The action the Department intends to take.
The effective date of the action.
The reasons for the action.
The rules that support the action.
The date the notice is mailed.
4
What Must a Decision Notice
Include, con’t.
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Client’s right to an impartial hearing if they
disagree with the Department's decision.
Methods and deadlines for requesting a
hearing.
Client’s right to representation, including legal
counsel, and the right to have witnesses
testify on their behalf.
Information about the availability of free legal
help.
5
Types of Decision Notices
461-175-0050

Basic Decision Notice

Continuing Benefit Decision Notice
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Timely Continuing Benefits Notice
6
Basic Decision Notice
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Is mailed no later than the planned date of
action.
Does not give the client the right to
continuation of benefits.
Examples: denial of application for medical or
approval of SNAP
7
Continuing Benefits Decision
Notice
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Is mailed in time to be received by the date
benefits are, or would be, received.
Gives information on the benefit group’s right
to continuing benefits.
Examples: Increase in the client liability due
to a change in client income, or reducing or
closing SNAP based on an interim change
report.
8
Timely Continuing Benefits
Decision Notice
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Is mailed no later than ten calendar days
before the effective date of the action.
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Start the 10-day count the day after the notice is
mailed.
Gives information on the benefit group’s right
to continuing benefits.
Examples: Closure of in-home services or a
reduction in SNAP amount.
9
Question 1
All decision notices must include the
hearing rights (DHS 447 or equivalent).
True or False?
10
When are decision notices
required? 461-175-0200

Basic Decision Notice:
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Application for assistance is approved or denied.
Denial of a request for aid paid pending.
Timely continuing benefit decision:
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Sent when benefits are reduced or closed.
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Note: A notice to reduce or close benefits
becomes VOID if the reduction or closure is not
initiated on the date stated on the notice (unless
the delay resulted from the client requesting a
hearing).
11
Situations that Do Not Require
Notice
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Benefits are ended due to the only eligible
person dying.
A hearing order upholds the department
decision and a notice was sent before the
client requested a hearing.
If a client signs the SDS 540A, that serves
as the decision notice. They still have
hearing rights.
12
Effective Dates
13
Effective dates for notices
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Effective dates are different depending on the type
of program and the action you intend to take.
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Read the rules carefully when deciding on what
effective date to use.
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All of the rules for effective dates can be found in
Chapter 461, Division 180.
14
Closures & reductions
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The effective date for closing Medical or
SNAP is typically the end of the month in
which the 10 day notice was sent (notice sent
05/11/10, effective date for closure is
05/31/10).
The effective date for reducing Medicaid or
SNAP is the first of the month following the
10 day notice (Notice sent 05/18/10 for
reduction effective 06/01/10).
15
Denials
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Medical/SNAP: The effective date for
denying benefits is the date of the notice.
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Services: The effective date for denying
services is the date you determine the client
is not eligible for service.
16
Approving QMB benefits
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The effective date for starting QMB is the first
of the month following the month in which
all verifications were received. (DOR
07/03/10; all verification rec’d 07/10/10; start
date 08/01/10)
The effective date for starting SMB/SMF is
the first of the month in which all
verifications were received. (DOR 07/03/10;
all verification rec’d 07/10/10; start date
07/01/10)
17
Closing Services
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Services can be closed after giving 10 days
notice. For example: Notice sent 07/15/10;
effective date can be 07/25/10).
The effective date for a change in pay-in
amount is the first of the next month after the
notice period (pay-in increase effective
06/01/10; notice sent 05/15/10). Use the
540P form.
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Closing Services
Reducing Medical
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When you close services, you must review the
client’s income to determine whether their eligibility
for Medicaid will be affected.
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For example: a client has $1050 in income and
waivered services are ending. Their income &
resources are below the SMB standard, so you
would send a CLOSURE notice for services and a
REDUCTION notice for their medical benefits.
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Closing Services and Medical
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If the client’s income makes them ineligible
for any other Medicaid program and the client
is losing services, you must send a 540 to
close services and a 540 and 0462A to close
medical benefits.
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Question 2
A 10-day notice is required to deny an
application for service benefits.
True or False?
21
Special Medicaid Notice Issues
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Denials, reductions, or closure notices
for Medicaid must include:
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DMAP rule 410-120-1210 which discusses
the coverage of the medical benefit
packages.
For closures & denials only, send the
0462A form in addition to the 540.
22
DHS 0462A, and 0462S
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Sent with the 540 when benefits are denied
or closed.
The purpose is to let the client know they
have been reviewed for all possible programs
before being denied-something the
Administrative Law Judges insist upon in
hearings.
Medicaid law (federal regulations) require
that a review of eligibility for all possible
Medicaid programs be done.
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SPD Worker Guide G.9
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Use for reasons and rule numbers on the
0540
Includes all programs
Denials, reductions and closures
Be sure to review the OARs every time you
use an example from the Worker Guide
examples.
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Notice Example 1-Question 3
Per the CAPS assessment done on 04/20/10
you are no longer eligible for waivered
services. However, you are eligible for 20
hours of personal care. OAR 411-015-0000
and OAR 411-015-0005.
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What is wrong with this notice?
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Notice Example 1-Question 3
1.
2.
3.
4.
Reason for ineligibility not cited.
“Waivered services” is not plain language.
All applicable rules are not cited.
All of the above.
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Notice Example 2 – Question 4
OAR 411-034-0000 to 411-034-0090: No longer
eligible for in home service plan due to being
SL 17. Eligible for SPPC.
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What is wrong with this notice?
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Notice Example 2 – Question 4
1.
2.
3.
4.
5.
Too many rules.
Too many acronyms.
Client’s limitations are not clearly explained.
All applicable rules are not cited.
2, 3, and 4
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Notice Example 3 – Question 5
See attachment.
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What is wrong with this notice?
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Notice Example 3 – Question 5
1.
2.
3.
4.
5.
The attachment may not be attached.
All applicable rules are not cited.
Should include an explanation of what is
happening & why.
Reason is required to be at least 3
sentences.
1, 2 and 3.
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Question 5 con’t.
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In order to be sufficient, an attachment to a
540 would have to include the action, the
effective date, the client’s name and case
number, the date the notice is sent, the
supporting OARs, an explanation, and
language indicating that the attachment is a
continuation from the notice.
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Now a few good examples. . .
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Service Closure
Your ability to meet your personal care needs in activities of daily
living has improved. This decision is based on the information
obtained from you at an interview and assessment performed on
07/02/10. Your current service priority level is 17. The Department
serves service priority level 1 through 13. Since your current service
priority level is not within this range, your long-term care services will
end 07/31/10. The Department has reviewed your eligibility for all
service programs. You do not qualify for any of them. OAR 411-0150005 through 411-015-0100; 411-030-0020; 411-030-0050; 411034-0000 through 411-034-0030
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Service Reduction
Your ability to meet your daily needs has improved.
This decision is based on the information obtained
from you at an interview and assessment performed
on 07/11/2010. You no longer require assistance with
toileting. Your in home service plan will be reduced by
10 hours per month to reflect that you no longer
require help in this area. The total number of care
plan hours you will receive is 40 hours per month
effective 08/01/2010. OAR 411-015-0005 through
411-015-0100; 411-030-0020 through 411-0300070.
34
Notice: Other incurred medical
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Use the SDS 0540M.
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Notice: Pay-in Increase
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Use the SDS 0540P.
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Notice: Disqualifying Transfer
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Use the SDS 0540T.
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Send the 0462A if a closure or denial.
37
OHP Denial
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The Oregon Health Plan (OHP) program is closed
to new applicants unless selected from the
reservation list. Your date of request for OHP is
07/02/10. You are considered a new applicant for
OHP because your date of request is after July 1,
2004 and you were not selected from the
reservation list. The Department has considered
other medical programs and there are no medical
programs for which you are eligible. OAR 410120-1210, 461-135-1102
Send the 0462A and 540.
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Contingent Language
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AVOID CONTINGENT LANGUAGE IN YOUR
NOTICES!
 Contingent language should never be used.
Here’s an example of contingent language:
You failed to provide verification of your new
income from work by 07/20/10. If you do not
provide this information to me before 07/31/10,
your benefits will close. If you provide it to me, we
can keep your benefits open after 07/31/10.
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Notice of Verification or
Information Needed (DHS 210A)
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This notice is used to request more information.
The 0210A is NOT a decision notice as it does not
tell the client that we are taking action. It simply
asks for more information.
Use for ongoing cases where circumstances
change:
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Send the client a 210A listing the information requested
and the due date for receipt of the info.
If the client fails to send the required info by the specified
date, you must send a decision notice to close the case.
Use form 540 Notice of Planned Action for the closure.
40
Food Stamp 210A Notice
Example
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The worker sends a 210A when the client
needs to provide more info. This is what the
210A contains:
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Date: 07/01/2010
Date Info Needed: 07/31/2010
Item Needed: Social Security Card or Proof of SSN
for new spouse
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If this info is not received. . .
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By 07/31/10, the worker should send a
decision notice (540) to tell the client what
action DHS will take:
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We requested verification from you regarding
David’s Social Security Number. We have not
received this verification so your benefits will
close on 07/31/2010.
42
Notification of Pending Status
SDS 539H
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New version on the Forms Server
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Can be used as a notice for expedited FS clients.
Includes notice language and hearing rights.
Oregon ACCESS version can be used to
inform clients of pending items but a decision
notice must also be sent.
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Cannot be used as a notice for expedited SNAP
clients.
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NF Financial Planning Form
SDS 0458A
New version on the Forms Server
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Can be used to send notice of change in liability.
Version includes rules in section (3) and hearing
rights.
Oregon ACCESS version can be used as a
notice IF:
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1.
2.
Rules 461-160-0610 & 461-160-0620 are added
to section (3); and
Hearing rights are attached (DHS 447)
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Notices
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In additional to those mentioned today:
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AFS 456M - Notice of Change in Reporting
SPD 0850E – EPD Notice of Participant Fee
CMS/FSMIS automated approval & closure
notices
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HELP! With Writing a Notice
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Writing a decision notice is not easy. Many
situations that require a denial, closure, or reduction
can become very complex.
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Ask for help if things are getting too complicated on
the notice!
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Technical Assistance
Medicaid
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Joanne Schiedler 503.947.5201
[email protected]
Michael Avery 503.945.6410
[email protected]
Jeff Stell 503.945.6834
[email protected]
Bill Brautigam 503.947.5204
[email protected]
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Technical Assistance
Program Specific Contacts
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FS: FS Policy Unit 503.945.5826
[email protected]
PMDDT: Brian Kirk 503.373.0271
[email protected]
In-Home: Jenny Cokeley 503.945.5799
[email protected]
IC: Kelsey Weigel 503.945.6413
[email protected]
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Web references
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Other resources:
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Decision Notice Language WG G.9:
http://www.dhs.state.or.us/spd/tools/additional/workergd/g.
9.htm
10-day notice WG G.7:
http://www.dhs.state.or.us/spd/tools/additional/workergd/g.
7.htm
Decision notice policy GPE D :
http://www.dhs.state.or.us/spd/tools/additional/generic/d.ht
m#01
Hearings rep website:
http://www.dhs.state.or.us/training/hearing_reps/
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Questions?
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