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• If applicable, the amount of medical expenses which must be incurred to meet a deductible. • If applicable, basic information on the level of benefits and services available based on the individual's eligibility including: ◦ A description of any premiums and cost sharing required ◦ An explanation of how to receive additional detailed information on benefits and financial responsibilities ◦ An explanation of any right to appeal the eligibility status or level of benefits and services approved 23.1.3 Notice of Denial Any notice of denial of eligibility for an individual or the household must include: • The month(s) that were denied and which individuals were determined ineligible. • The reason(s) for the denial, including citations to the law or policy that supports the action. • An explanation of the right to a fair hearing and how to request one. 23.1.4 Notice of Adverse Action An adverse action is a change made by an IM agency that will stop or reduce benefits or increase cost sharing. Members have the right to adequate and timely notice of an adverse action. 23.1.4.1 Adequate Notice of Adverse Action To be “adequate,” a notice of an adverse action must include the following: • A statement describing the intended action • The reason(s) for the intended action, including a citation to the law, regulation, rule, or policy that supports or requires the action • An explanation of the right to a fair hearing and how to request one • A statement on the availability of free representation • A statement that if a hearing is requested before the action's effective date, benefits will continue until the hearing decision is made • A statement that the member may have to repay any benefits continued during the appeal if the hearing decision isn't in their favor or they abandon or withdraw the hearing request • The telephone number of the income maintenance agency to contact for more information 23.1.4.2 Timely Notice of Adverse Action Notice must be provided at least 10 days before the effective date of any intended adverse action unless one or more of the following circumstances apply: • Factual information confirms a recipient or payee's death and there is no relative to take their place as primary person. • A clear, written statement initiated and signed by the member is submitted stating they no longer wish to receive benefits. • The member has applied for and is receiving benefits from another state. This page last updated in Release Number: 25-04 Release Date: 12/10/2025 Effective Date: 12/10/2025