2701 Notification

Georgia State Seal

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Notification

Effective Date:

May 2023

Chapter:

2700

Policy Number:

2701

Previous Policy Number(s):

MT 60

Updated or Reviewed in MT:

MT-69

Requirements

Written notice to the AU is required when any of the following occur:

  • approval or denial of an application for benefits

  • change in patient liability/cost share

  • addition or deletion of an individual in an AU

  • denial, reduction, or termination of an individual’s benefits because of a sanction, penalty, or ineligibility

  • termination/reduction of benefits to the AU or to an AU member.

Basic Considerations

Written notifications must include the following:

  • the proposed action

  • the reason for the action

  • period of eligibility

  • notification of appeal rights and information regarding the filing of an appeal

  • the availability of free legal representation, including telephone number

  • a telephone number to contact for additional information

  • the specific Medicaid regulation must be cited for denials.

Written notice is program specific and is generated by the system. When system-generated notice explanation is inadequate, additional documentation on the notice is required. Generic denial reasons may be used as a secondary or tertiary denial/termination reason, but never as the sole reason for denial/termination.

Written notice can be mailed to the AU or hand delivered to the AU during an interview.

Adequate notice is a written communication provided to the AU no later than the date the action is taken.

Timely notice is a written communication provided to the AU with at least a 14-day waiting period before the date the proposed action is effective.

Procedures

Adequate Notice

Provide adequate notice in the following circumstances:

  • mass changes in benefits initiated by the State or federal government including the following:

    • TANF, RSDI and SSI adjustments

    • financial standards and benefits levels

    • deductions

  • death of all members of the AU reported through reliable information

  • a decrease in PL/CS

  • an increase in PL/CS if fourteen days remain in the month in which the change is to be effective (notice and change are effective the same month)

  • denial of an application

  • a clear written statement from the A/R requesting termination of benefits for the entire AU

  • a written request by the AU for voluntary termination

  • the AU reports information in writing and ineligibility can be determined without verification

  • benefits were approved for a specific time period and the AU was informed in writing of the proposed termination, or change in benefits at approval

  • the AU moves out of state.

Timely notice

Implement the proposed change effective the month following the expiration of the 14 day timely notice period. (Exception may be increases/decreases in PL/CS. See bullets above and below.)

If the AU provides information within the 14-day timely notice period that alters the proposed change, stop the action and reevaluate the circumstances.

Allow the system to automatically track the 14-day timely notice period if the action is entered in the system.

Manually track the 14-day timely notice if a manual notice is sent. The AU may request a fair hearing and continuation of benefits. Refer to Appendix B, Hearings for policy regarding continuation of benefits.

Provide timely notice in the following circumstances:

  • changes in AU circumstances causes termination/reduction of benefits

  • increase in patient liability/cost share if 14 days do not remain in the month in which the notice would be sent

    Do not make the change for the current month; make change effective the ongoing month when adequate notice can be given.

  • mail returned and/or whereabouts unknown

Notice of Fair Hearing

The following language must be included on all adverse action communications:

“If you do not agree with any action taken on your Medicaid case, you have the right to ask for a fair hearing before a state hearing officer. You may be represented at the hearing by a lawyer, relative, friend or anyone you choose. If you want a hearing on your Medicaid case you must ask for the hearing in writing within thirty (30) days from the date of this notice.”

If the hearing request is to continue receiving benefits while waiting for a hearing decision, the notices must clearly state that they may be required to repay the Department of Community Health.

The following agency information must also be included on all adverse action notifications:

  • Georgia Legal Services Program

  • Atlanta Legal Aid

  • Georgia Senior Legal Hotline

  • Office of the State Long-Term Ombudsman

  • Georgia Advocacy Office, Inc.