101.15.11B REDUCTION OR TERMINATION OF BENEFITS

Advance notice of adverse action is required, if the eligibility decision results in termination of benefits for all or some members of the case. During the adverse action period, the recipient or head of household is allowed time to fully comply with unmet redetermination requirements, provide information or verification that will alter the adverse action decision or request a fair hearing with continued benefits. For MAGI-related cases, adverse action is required in the following situations: • Termination of benefits for one or all members of the household • Change from Medicaid to CHIP • Change from CHIP to Medicaid • Conversion to a reduced services coverage group For ABD cases, adverse action is required in all the following situations: • Termination of benefits. • Conversion to a reduced services coverage group. • Termination of a nursing facility per diem payment. The system is not programmed for the case to remain open during the adverse action period; however, eligibility staff must treat the case as if it is open until the period has ended. During this period if the ABD recipient or MAGI head of household subsequently complies with all redetermination requirements or provides information which changes the negative action, eligibility must be reinstated. If the client requests a hearing, with continued benefits, the case must be promptly reinstated. Specialists must take prompt action on the information provided during the advance notice period. Timely action must be taken to prevent a break in coverage, whether the client takes action within the first few days of the adverse action period or on the final day. ABD Example: The recipient did not provide income verification needed for the May redetermination. The closure is authorized on May 10th and advance notice is mailed to the recipient advising that eligibility will terminate effective May 31st. On May 18th, within the advance notice period, the verification is received in the office. The specialist takes action to process the case as a reinstatement and determines eligibility using the current income. The supervisor then reviews the action and authorizes the eligibility decision. Appropriate notice is issued to the client and there is no break in coverage. MAGI Example: The head of household failed to comply with redetermination requirements for a May redetermination. The case was closed on May 15th effective May 31st. On May 29th partial verification is provided; however, all information needed to process the case is not provided. A reinstatement contact is registered for May 29th. A 307 is issued for the information and 30-day processing is applicable.