22-02 Version of 29.1 Notices

A notice must be either mailed or sent electronically at least 10 days prior to the effective date of an adverse action, such as a termination of benefits or an increase in premium.

29.1.1 Notice Requirements

Applicants and members must receive written notice of:

• The decision on an application or renewal
• Any action to discontinue or suspend a member’s benefits
• Any action that changes the form or amount of benefits

29.1.2 Notice of Approval

Any notice of approval of eligibility must include:

• The basis and effective date of eligibility and which individuals are eligible
• The circumstances under which the individual must report and procedures for reporting any changes that may affect the individual's eligibility
• If applicable, the amount of medical expenses that 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

29.1.3 Notice of Denial

Any notice of denial of BC+ 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

29.1.4 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.

29.1.4.1 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 and the name of the agency to contact for more information 

29.1.4.2 Timely Notice of Adverse Action

Timely 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