68.02 Advance notice of Medicaid adverse action decision118

In general. AHS will send a notice of a decision that adversely affects an enrollee’s Medicaid eligibility, including a notice of termination, reduction, suspension of eligibility, or increase in liability, as described at § 68.01(a), (adverse action) at least 11 days before the date the adverse action is to take effect (date of adverse action), except as permitted under paragraph (b) of this subsection. (b) Exception.119 A notice may be sent not later than the date of adverse action if: There is factual information confirming the death of an enrollee; A clear written statement signed by an enrollee is received that: (i) The enrollee no longer wishes eligibility; or (ii) Gives information that requires termination or reduction of eligibility and indicates that the enrollee understands that this must be the result of supplying that information; The enrollee has been admitted to an institution where they are ineligible; The enrollee’s whereabouts are unknown and the post office returns mail directed to the enrollee indicating no forwarding address; or AHS establishes the fact that the enrollee has been accepted for Medicaid eligibility by another state, territory, or commonwealth. 117 42 CFR § 431.206(c). 118 42 CFR § 431.211. 119 42 CFR § 431.213. Eligibility-and-Enrollment Procedures Part 7 – Page 55 (Sec.69.00, Sub.70.01) (c) Exception: probable fraud.120 The period of advance notice may be shortened to 5 days before the date of adverse action if: There are facts indicating that adverse action should be taken because of probable fraud by the enrollee; and The facts have been verified, if possible, through secondary sources. Medicaid corrective payment121 (10/01/2021, GCR 20-004) Corrective payments will be promptly made, retroactive to the date an incorrect Medicaid action was taken if: A fair hearing decision is favorable to an individual; or (b) An issue is decided in an individual’s favor before a fair hearing. Medicaid enrollment (01/01/2023, GCR 22-033)