225-4 Good Cause for Non-Cooperation with TPL

Effective Date: September 1, 2018

Previous Policy

An applicant or recipient who can establish "good cause" may receive Medicaid without completing TPL requirements. Good cause means the individual has an acceptable reason for not cooperating with TPL. See A below.

Eligibility workers must sent the form TPL-1 which explains good cause for non-cooperation with TPL and the consequences for non-cooperation without good cause to applicants and recipients who claim good cause.

The applicant or recipient must provide information or evidence to show that good cause may exist.

Do not deny, delay, or stop assistance during the process of deciding if good cause exists.

Reasons and Proof of Good Cause

Applicants or recipients may claim good cause to protect the best interests of the family. Good cause includes the following circumstances:

The child on Medicaid was conceived because of incest or forcible rape.

Evidence : Birth certificates; Department of Health and Human Services, court, or law enforcement records.

Legal proceedings for the adoption of a child on Medicaid are pending before a court of competent jurisdiction.

Evidence : Court records; Department of Health and Human Services records; placement agreement; adoption agency or attorney report.

A public or licensed private social agency is helping the applicant or recipient make a decision concerning possible adoption of the child on Medicaid, AND the discussions have not gone on for more than three months.

Evidence : Written notice from the social agency working with the individual.

Cooperation with TPL is expected to result in physical or emotional harm to the individual, the spouse, or any of the individual's children. Emotional harm is any emotional impairment that substantially affects functioning. If the claim is based in whole or in part on anticipated emotional harm, consider the present emotional health, history of emotional health, intensity and probable duration of emotional impairment, degree of cooperation required, and extent of involvement required. Document these considerations carefully in the case record.

Evidence : Medical records or written statements from a mental health professional; court records; medical records; Department of Health and Human Services or Workforce Services records showing it is reasonable to expect harm to result from TPL cooperation.

Determine Good Cause

The supervisor will decide if the individual has good cause for non-cooperation with TPL. When the supervisor decides if good cause exists, send a notice to the applicant/recipient. Individuals may appeal the decision through the administrative hearing process.

Decide based on:

Information contained in any Department of Health and Human Services or Workforce Services records,

Evidence supplied by the applicant/recipient,

Investigation of the evidence provided, or

A combination of evidence and investigation.

Evidence

The applicant or recipient must provide supporting evidence within 20 days from the date good cause is claimed. The supervisor may grant an extension. Note the extension in the case file. The eligibility worker should help the individual get the necessary evidence.

If the person anticipates physical harm but cannot provide supporting evidence of abuse or threats of abuse, you may accept sworn statements from people with knowledge of the circumstances and personal knowledge about the applicant or recipient. The sworn statements do not need to establish that abuse has occurred or been threatened, but must support the individual's credibility. The supervisor will decide if the person has established good cause.

Investigation of good cause Claim

The supervisor will investigate the good cause claim if evidence is not available.

When doing an investigation, use any reasonable evidence that is easily accessible. Investigation may include contact with government or private social service agencies, or individuals who may have knowledge of the circumstances and could provide information to support the individual's claim.

Do not release information from DWS or DHHS records to others outside DWS or DHHS. Do not release information to anyone within DWS or DHHS unless the person has a valid, work-related need to know the information.

DO NOT give information to anyone who may harm the individual or the individual's family.

Contact with an absent parent might be necessary to establish good cause. Before making contact, the applicant or recipient must be notified and must respond. He or she may:

Allow the contact, or

Present more evidence so the contact is unnecessary, or

Agree to denial of the good cause claim, or

Withdraw the application or request removal from the case.

Enforcement Without Cooperation

If the individual has good cause for non-cooperation, the supervisor must decide if ORS could pursue verification of the TPL, collection, and enforcement without harming the individual or the individual's family WITHOUT THE COOPERATION OF THE INDIVIDUAL. Record the decision in the case file and notify ORS. Before ORS proceeds with action, notify the applicant or recipient and record his or her response.

When the supervisor has decided ORS can pursue TPL without harming the individual or the individual's family, the individual must either:

allow the collection or enforcement, OR

withdraw the application, OR

request removal from the case.