Reductions, Denials, and Terminations 535-05-50

(Revised 10/01/2024 ML #3871)

An individual dissatisfied with a decision made regarding personal care services may appeal that decision to the Department of Human Services under the fair hearing rules set forth in N.D.A.C. 75-01-03-03. An individual must be informed of the right to appeal any actions by the case manager or the department that result in denial, suspension, reduction, discontinuance, or termination of personal care services. Refer to Service Chapter 448-01-30 for more information with regard to Hearings and Appeals.

Denial/Termination/Reduction

The applicant/individual must be informed in writing of the reason(s) for the denial/termination/reduction.

The HCBS Notice of Denialor Termination form (SFN 1647/DD - SFN 1008) is dated the date of the mailing. Contact the HCBS Program Administrator to obtain the legal reference required at “as set forth . . . ." The legal reference must be based on federal law, state law and/or administrative code; and may include a policy and procedures manual reference(s). The citation used to complete the SFN 1647 must be obtained from a HCBS Program Administrator or the HCBS Unit Supervisor of Aging Services. The citation used to complete the SFN 1008 must be obtained from the Residential and Vocational Services Administrator.

The individual must be notified in writing at least 10 days (it may be more) prior to the date of terminating or denying services (UNLESS it is for one of the reasons stated in this section that does not require a 10-day notice). The date entered on the line, the effective date field, is 10 calendar days from the date of mailing the Notice (SFN 1647) (SFN 1008 for DD) or the next working day if it is a Saturday, Sunday, or legal holiday.

Termination of a service is discontinuing the service. The individual must be informed in writing of the termination by providing the individual with a completed SFN 1647 (SFN 1008 for DD) or the individual may provide a written statement indicating they no longer want the service.
Denial of a service may include denying the service to a new applicant or denying the number of units a current individual requests.

When denying units the individual has requested, the individual must be informed in writing of the Denial by providing the individual a completed SFN 1647 (SFN 1008 for DD).

When an individual contacts the HCBS Case Manager or DDPM per phone for general information about the service, the applicant must be made aware that a formal determination of eligibility for the service cannot be made by phone. The individual must be offered the option to complete an Application for Services SFN 1047. Upon receipt of the completed SFN 1047 a home visit would be scheduled to determine eligibility.

After the SFN 1047 is received and a formal assessment is completed the individual must be informed in writing of the Denial by providing theindividual with a completed SFN 1647 (SFN 1008 for DD) or the individual may provide a written statement indicating they do not want the service.

When a home visit is completed to assess or inform an applicant about services, an application for service is implied by the individual and a completed SFN 1647 (SFN 1008 for DD) must be provided informing the individual of the Denial or the client can provide a written statement indicating they do not want the service.

Reduction in services may include reducing the number of units or reducing the tasks in a specific category. A written reduction notice is required (the individual agreeing with the reduction is not sufficient).

If the service is reduced the individual must be informed in writing of the reason(s) for the reduction in service on the SFN 662, the effective date of the reduction must be no sooner than 11 days after the individual signs the SFN 662 and the individual must be given a copy of the appeal rights printed on back of the SFN 662.

Any of the reasons below do not require a 10-day notice:

The individual enters a nursing home.
Aging Services (Developmental Disabilities Section for DD) or Human Service Center has received in writing the individual’s decision to terminate services.
Individual’s whereabouts are unknown and attempt to contact the individual are supported by documentation in the client's file.
State or federal government initiates a mass change which uniformly and similarly affects all similarly situated applicants, recipients, and households.
Case Management has factual information confirming the death of the individual.

Personal Care Service has not been used in 60 days:

The authorization for personal care service may be terminated if the service is not used within 60 days, or if services lapse for at least 60 days, after the issuance of the authorization to provide personal care services.

Health Welfare and Safety:

The department may deny or terminate personal care services when service to the individual presents an immediate threat to the health or safety of the individual, the provider of the service, or others, or when the services that are available are not adequate to prevent a threat to the health or safety of the individual, the provider of services, or others.

The individual is no longer eligible for Medicaid:

Case Manager must send a letter to the individual that eligibility for MSP-PC is dependent on eligibility for Medicaid (the right to appeal the closure of the Medicaid benefit is sent to the individual by Economic Assistance).