"Good Cause" -- Third Party Liability 510-05-12-10

(Revised 1/03 ML #2833)

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The requirement to cooperate may be waived when an applicant or recipient has "good cause" not to cooperate.

There is no particular form used to claim "good cause"; however, the applicant or recipient will need to provide information and evidence to substantiate the claim. If "good cause" is claimed the applicant or recipient can be eligible for Medicaid while the decision is pending.

The determination of whether there is good cause is made by the county agency. The county agency may waive the requirement to cooperate if it determines that cooperation is against the best interests of a child in the unit. Cooperation is against the best interests of a child only if the applicant or recipient’s cooperation is reasonably anticipated to result in:

Physical or emotional harm to a child in the Medicaid unit; or

Physical or emotional harm to the parent or caretaker with whom the child is living, of such nature or degree that it reduces such person’s capacity to care for the child adequately.

There must be evidence to substantiate a claim of "good cause." Exemptions on the basis of physical or emotional harm, either to the child, parent, or caretaker must be of a genuine and serious nature. Mere belief that cooperation might result in harm is not a sufficient basis for finding "good cause." Evidence upon which the county agency bases it’s finding must be supported by written statements and contained in the case record.

It is the applicant or recipient’s responsibility to provide the county agency with the evidence needed to establish "good cause." The applicant or recipient is normally given 20 days from the date of claim to collect the evidence. In exceptional cases, the county agency may grant reasonable additional time to allow for difficulty in obtaining proof. Records of law enforcement, social service, or adoption agencies may be readily available to document instances of physical harm, perhaps without requiring further investigation. Documentation of anticipated emotional harm to the child, parent, or caretaker, however, may be somewhat more elusive. Whenever the claim is based in whole or in part on anticipated emotional harm, the county agency must consider the following:

The present emotional state, and the emotional health history, of the individual subject to emotional harm;

The intensity and probable duration of the emotional impairment;

The degree of cooperation to be required; and

The extent of involvement of the child in pursuing third parties who may be liable to pay for care or services.

Upon request, the county agency is required to assist the applicant or recipient in obtaining evidence necessary to support a "good cause" claim. This, however, is not intended to place an unreasonable burden on staff, shift the applicant or recipient’s basic responsibility to produce evidence to support the claim, or to delay a final determination.

The county agency is directly responsible for investigating a "good cause" claim when it believes that the applicant or recipient’s claim is authentic, even though confirming evidence may not be available. When the claim is based on a fear of serious physical harm and county agency staff believes the claim, investigation may be conducted without requiring corroborative evidence by the applicant or recipient. It may involve a careful review of the case record, evaluation of the credibility of the applicant or recipient’s statements, or a confidential interview with an observer who has good reasons for not giving a written statement. Based on such an investigation, and on professional judgment, the county agency may find that "good cause" exists without the availability of absolute corroborative evidence.

Except for extenuating circumstances, the "good cause" issue must be determined with the same degree of promptness as for the determination of other factors of eligibility (45 days). The county agency may not deny, delay, or discontinue assistance pending the resolution of the "good cause" claim.

The applicant or recipient and the Third Party Liability unit must be informed of the "good cause" decision. The applicant or recipient must be informed, in writing, of the county agency’s final decision that "good cause’ does or does not exist and the basis for the findings. A copy of this communication must be maintained in the case record. If "good cause" was determined not to exist, the communication must remind the applicant or recipient of the obligation to cooperate if he or she wishes to be eligible for Medicaid, of the right to appeal the decision, and of the right to withdraw the application or have their eligibility terminated.

The county agency must review the "good cause" decision at least every twelve months. If "good cause" continues to exist, the applicant or recipient must again be informed in writing. If circumstances have changed so "good cause" no longer exists, the applicant or recipient must be informed, in writing, and given the opportunity to cooperate, terminate assistance, withdraw the application, or appeal the decision. The Third Party Liability unit must also be informed of whether or not "good cause" continues to exist.