Par.1.   Material Transmitted and Purpose -- Transmitted with this Manual Letter are revisions to Service Chapter 535-05, Medicaid State Plan Personal Care Service Policies and Procedures.  

Par. 2.   Effective Date – October 1, 2009

Appeals 535-05-50

 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 449-08 for more information with regard to Hearings and Appeals.
 
Denial/Termination/Reduction
The applicant/client must be informed in writing of the reason(s) for the denial/termination/reduction. The Case Manager is responsible to send a completed SFN 1647 with all applicable information to the client or applicant.

The Notice of Denial/Termination/Reduction form SFN 1647 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; reliance  and may include on a policy and procedures manual reference(s) is not sufficient.

The client must be notified in writing at least 10 days (it may be more) prior to the date of terminating/denying/reducing services UNLESS it is for one of the reasons stated in this section. The date entered on the line, the effective date field, is 11 calendar days from the date of mailing the Notice (SFN 1647) or the next working day if it is a Saturday, Sunday, or legal holiday.

If the service is reduced the client must be informed in writing of the reason(s) for the reduction in service on the SFN 662, the reduction in service  becomes effective  no less than 10 days after the client signs the SFN 662 and the client must be given a copy of the appeal rights printed on back of the SFN 662.

•	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 client agreeing with the reduction is not sufficient). 
•	Termination of a service is discontinuing the service. The client must be informed in writing of the Termination by providing the client with a completed SFN 1647 or the client 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 client requests. 
o	When denying units the client has requested, the client must be informed in writing of the Denial by providing the client a completed SFN 1647.
o	When a home visit is completed to assess or inform an applicant about services, an application for service is implied by the client and a completed SFN 1647 must be provided informing the client of the Denial or the client can provide a written statement indicating they do not want the service.
o	When a client contacts the HCBS Case Manager or DD Case Manager 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 client 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 client must be informed in writing of the Denial by providing the client with a completed SFN 1647 or the client may provide a written statement indicating they do not want the service.

Any of the reasons below do not require a 10-day notice:
1.	The client enters a nursing home.
2.	The county or Human Service Center has received in writing the client’s decision to terminate services.
3.	The client agrees with the plan of care. 
3. 4.	Client’s whereabouts are unknown and attempts to contact the client are supported by documentation in the clients file. 
4. 5.	State or federal government initiates a mass change which uniformly and similarly affects all similarly situated applicants, recipients, and households.
5. 6.	Case Management has factual information confirming the death of the client.

The client is no longer eligible for Medicaid:
The Case Manager must send a letter informing the client 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 client by Economic Assistance).

Forms 535-05-70
 
 Application for Service, SFN 1047 535-05-70-15

Purpose:  For individuals to formally request Home and Community Based Services and Medicaid State Plan Personal Care Service.

Prior to conducting a comprehensive assessment, an applicant (or legal representative) must complete the application form.  
•	Date – date of application;
•	Agency – County Social Service Board of applicant’s physical county;
•	Name – print the name of the applicant (one SFN 1047 per applicant);
•	I apply for services to assist me with – the applicant indicates what services or programs for which the applicant is requesting assistance;
•	FOR YOUR INFORMATION – applicant must read this section prior to signing;
•	The applicant must check to acknowledge the receipt of the "Your Rights and Responsibilities" brochure. (The Brochure # is DN46 (0606)
•	Signature section – the applicant and/or the legal representative must sign and date the application form.