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Writing Good Decision Notices. July 2010 Chris Ellis, SPD Hearing Representative. Objectives. Outline the types of decision notices and the elements required on each notice. Understand the difference between an adequate and inadequate notice.

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Writing good decision notices

Writing Good Decision Notices

July 2010

Chris Ellis, SPD Hearing Representative


Objectives
Objectives

  • 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.


What is a decision notice 461 175 0010
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.


What must a decision notice include 461 175 0010
What Must a Decision Notice Include? 461-175-0010

  • 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.


What must a decision notice include con t
What Must a Decision Notice Include, con’t.

  • 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.


Types of decision notices 461 175 0050
Types of Decision Notices461-175-0050

  • Basic Decision Notice

  • Continuing Benefit Decision Notice

  • Timely Continuing Benefits Notice


Basic decision notice
Basic Decision Notice

  • 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


Continuing benefits decision notice
Continuing Benefits Decision Notice

  • 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.


Timely continuing benefits decision notice
Timely Continuing Benefits Decision Notice

  • Is mailed no later than ten calendar days before the effective date of the action.

    • 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.


Question 1
Question 1

All decision notices must include the hearing rights (DHS 447 or equivalent).

True or False?


When are decision notices required 461 175 0200
When are decision notices required? 461-175-0200

  • Basic Decision Notice:

    • Application for assistance is approved or denied.

    • Denial of a request for aid paid pending.

  • Timely continuing benefit decision:

    • Sent when benefits are reduced or closed.

    • 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).


Situations that do not require notice
Situations that Do Not Require Notice

  • 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.



Effective dates for notices
Effective dates for notices

  • Effective dates are different depending on the type of program and the action you intend to take.

  • Read the rules carefully when deciding on what effective date to use.

  • All of the rules for effective dates can be found in Chapter 461, Division 180.


Closures reductions
Closures & reductions

  • 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).


Denials
Denials

  • Medical/SNAP:The effective date for denying benefits is the date of the notice.

  • Services:The effective date for denying services is the date you determine the client is not eligible for service.


Approving qmb benefits
Approving QMB benefits

  • 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)


Closing services
Closing Services

  • 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.


Closing services reducing medical
Closing Services Reducing Medical

  • When you close services, you must review the client’s income to determine whether their eligibility for Medicaid will be affected.

  • 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 REDUCTIONnotice for their medical benefits.


Closing services and medical
ClosingServices and Medical

  • 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.


Question 2
Question 2

A 10-day notice is required to deny an application for service benefits.

True or False?


Special medicaid notice issues
Special Medicaid Notice Issues

  • Denials, reductions, or closure notices for Medicaid must include:

    • 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.


Dhs 0462a and 0462 s
DHS 0462A, and 0462S

  • 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.


Spd worker guide g 9
SPD Worker Guide G.9

  • 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.


Notice example 1 question 3
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.

  • What is wrong with this notice?


Notice example 1 question 31
Notice Example 1-Question 3

  • Reason for ineligibility not cited.

  • “Waivered services” is not plain language.

  • All applicable rules are not cited.

  • All of the above.


Notice example 2 question 4
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.

  • What is wrong with this notice?


Notice example 2 question 41
Notice Example 2 – Question 4

  • Too many rules.

  • Too many acronyms.

  • Client’s limitations are not clearly explained.

  • All applicable rules are not cited.

  • 2, 3, and 4


Notice example 3 question 5
Notice Example 3 – Question 5

See attachment.

  • What is wrong with this notice?


Notice example 3 question 51
Notice Example 3 – Question 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.


Question 5 con t
Question 5 con’t.

  • 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.



Service closure
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 411-015-0005 through 411-015-0100; 411-030-0020; 411-030-0050; 411-034-0000 through 411-034-0030


Service reduction
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 411-030-0070.


Notice other incurred medical
Notice: Other incurred medical

  • Use the SDS 0540M.


Notice pay in increase
Notice: Pay-in Increase

  • Use the SDS 0540P.


Notice disqualifying transfer
Notice: Disqualifying Transfer

  • Use the SDS 0540T.

  • Send the 0462A if a closure or denial.


Ohp denial
OHP Denial

  • 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 410-120-1210, 461-135-1102

  • Send the 0462A and 540.


Contingent language
Contingent Language

  • 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.


Notice of verification or information needed dhs 210a
Notice of Verification or Information Needed (DHS 210A)

  • 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:

    • 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.


Food stamp 210a notice example
Food Stamp 210A Notice Example

  • The worker sends a 210A when the client needs to provide more info. This is what the 210A contains:

    • Date: 07/01/2010

    • Date Info Needed: 07/31/2010

    • Item Needed: Social Security Card or Proof of SSN for new spouse


If this info is not received
If this info is not received. . .

  • By 07/31/10, the worker should send a decision notice (540) to tell the client what action DHS will take:

    • 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.


Notification of pending status sds 539h
Notification of Pending Status SDS 539H

  • New version on the Forms Server

    • 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.

    • Cannot be used as a notice for expedited SNAP clients.


Nf financial planning form sds 0458a
NF Financial Planning Form SDS 0458A

  • New version on the Forms Server

    • 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:

    • Rules 461-160-0610 & 461-160-0620 are added to section (3); and

    • Hearing rights are attached (DHS 447)


Notices
Notices

  • In additional to those mentioned today:

    • AFS 456M - Notice of Change in Reporting

    • SPD 0850E – EPD Notice of Participant Fee

    • CMS/FSMIS automated approval & closure notices


Help with writing a notice
HELP! With Writing a Notice

  • Writing a decision notice is not easy. Many situations that require a denial, closure, or reduction can become very complex.

  • Ask for help if things are getting too complicated on the notice!


Technical assistance medicaid
Technical AssistanceMedicaid


Technical assistance program specific contacts
Technical AssistanceProgram Specific Contacts


Web references
Web references

  • Other resources:

    • 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.htm#01

    • Hearings rep website: http://www.dhs.state.or.us/training/hearing_reps/



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