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State of Wisconsin |
HISTORY |
The policy on this page is from a previous version of the handbook.
8.3.1 Claiming Good Cause Introduction
Any parent or other caretaker relative who is required to cooperate in establishing paternity and obtaining medical support may claim good cause. He or she must:
Specify the circumstance that is the basis for good cause, and
Corroborate the circumstance according to the evidence requirements in Section 8.3.5 Evidence
The IM agency must provide a Good Cause Notice (DWSP 2018) to all applicants and to members whenever a child is added to the Medicaid case. The notice describes the right to refuse to cooperate for good cause in establishing paternity and securing medical support.
The IM worker and the parent or caretaker must sign and date the notice. File the original in the case record and give the applicant/member a copy. The CSA refers anyone who wants to claim good cause back to the IM agency for a determination of whether or not good cause exists.
The Good Cause Claim form (DWSP 2019) must be provided to any Medicaid parent or caretaker who requests one. It describes the circumstances that support a claim and how to document a claim.
The parent or caretaker must sign and date the claim in the presence of an IM worker or a notary public. The applicant/member’s signature initiates the claim.
The original copy is filed in the case record, a copy is given to the parent or caretaker and a copy is attached to the referral document when a good cause claim is made at application.
A copy of good cause claims must be sent to the CSA within two days after a claim is signed. When the CSA is informed of a good cause claim, they will immediately suspend all activities to establish paternity or secure medical support until notified of your final determination.
The IM agency must determine whether or not cooperation is against the best interests of the child. Cooperation is waived only if:
The parent or caretaker’s cooperation is reasonably anticipated to result in physical or emotional harm to the:
Child. This means that the child is so emotionally impaired, that his or her normal functioning is substantially affected, or
Parent or Caretaker. This means the impairment is of such a nature or degree that it reduces that person's capacity to adequately care for the child.
At least one of the following circumstances exists and it is reasonably anticipated that proceeding to establish paternity or secure support or both would be detrimental to the child:
The child was conceived as a result of incest or sexual assault, or
A petition for the child's adoption has been filed with a court, or
The parent or caretaker is being assisted by a public or private social agency in deciding whether or not to terminate parental rights and this has not gone on for more than three months.
An initial good cause claim may be based only on evidence in existence at the time of the claim. There is no limit to the age of the evidence. Once a final determination is made, including any fair hearing decision, any subsequent claim must be based on new evidence.
The following may be used as evidence:
Birth certificates or medical or law enforcement records that indicate that the child may have been conceived as a result of incest or sexual assault.
Court documents or other records which indicate that a petition for the adoption of the child has been filed with a court.
Court, medical, criminal, child protective services, social services, psychological school, or law enforcement records which indicate that the alleged father or absent parent might inflict physical or emotional harm on the member or the child.
Medical records which give the emotional health history and present emotional health status of the member or the child.
A written statement from a mental health professional indicating a diagnosis of or prognosis on the emotional health of the member or the child.
A written statement from a public or private social agency that the agency is assisting the parent to decide whether or not to terminate parental rights.
A sworn statement from someone other than the member with knowledge of the circumstance on which the claim is based.
Any other supporting or corroborative evidence.
When a claim is based on emotional harm to the child or the member, the IM agency must consider the:
Person's present emotional state, and
Person's emotional health history, and
Intensity and probable duration of the emotional impairment, and
Degree of cooperation required, and
Extent of the child's involvement in the paternity or the support enforcement activity to be undertaken. If the member submits only one piece of evidence or inclusive evidence, you may refer him or her to a mental health professional for a report relating to the claim.
When a claim is based on his or her undocumented statement that the child was conceived as a result of incest or sexual assault, it should be reviewed as one based on emotional harm.
The IM agency must conduct an investigation when a claim is based on anticipated physical harm and no evidence is submitted.
The member has 20 days, from the date the claim is signed, to submit evidence. The IM agency, with supervisory approval, may determine that more time is needed.
There must be at least one document of evidence, in addition to any sworn statements from the member.
The IM agency should encourage the provision of as many types of evidence as possible and offer any assistance necessary in obtaining necessary evidence.
When insufficient evidence has been submitted:
The member must be notified and the specific evidence needed must be requested, and
The IM agency must advise that person on how to obtain the evidence, and
The IM agency must make a reasonable effort to obtain specific documents that are not reasonably obtainable without assistance.
If the parent or caretaker continues to refuse to cooperate or the evidence is still insufficient, a 10-day notice must be sent informing the parent or caretaker that if no further action is taken within ten days from the notification date, good cause will not be found and that he or she may first:
Withdraw the claim and cooperate, or
Exclude allowable individuals, or
Request a hearing, or
Withdraw the application or request that the case be closed.
If no option above has been taken when the ten days have expired the IM worker will deny Medicaid to the applicant or disenroll the member from Medicaid. The sanctions remain in effect until there is cooperation or until it is no longer required.
The IM agency must investigate all claims based on anticipated physical harm both when the claim is credible without corroborative evidence and when such evidence is not available.
Good cause must be granted when both the member's statement and the investigation satisfy you that he or she has good cause.
Any claim must be investigated when the member's statement together with any corroborative evidence does not provide a sufficient basis for a determination.
In the course of the investigation, neither the IM agency nor the CSA may contact the absent parent or alleged father without first notifying the member of your intention. Once notified the parent or caretaker has ten days from the notification date to:
Present additional supporting or corroborative evidence of information so that contact is unnecessary, or
Exclude allowable individuals, or
Withdraw the application or request that the case be closed, or
Request a fair hearing.
When the ten days have expired and no option has been taken the IM agency will deny Medicaid to the applicant or remove the member from the Medicaid card, and the sanctions shall remain in effect until there is cooperation or until it is no longer an issue.
The IM staff must determine whether or not there is good cause. This should be done within 45 days from the date a claim is signed. The time may be extended if it is documented in the case record that additional time is necessary because:
The IM agency cannot obtain the information needed to verify the claim within the 45 days, or
The parent or caretaker does not submit corroborative evidence within 20 days.
The good cause determination and all evidence submitted filed in the case record along with a statement on how the determination was reached.
If there is no evidence or verifiable information available that suggests otherwise, it must be concluded that an alleged refusal to cooperate was, in fact, a case of cooperation to the fullest extent possible.
If the parent or caretaker is cooperating in furnishing evidence and information, do not deny, delay, or discontinue Medicaid pending the determination.
If a fair hearing is requested on a good cause determination, Medicaid certification is continued until the decision is made.
The 45-day period for determining good cause is not used to extend an eligibility determination. The 30-day limit on processing an application is still a requirement.
The IM must notify the applicant/member in writing of the final determination and of the right to a fair hearing. Send the CSA a copy. The CSA may also participate in any fair hearing.
When good cause is granted, the IM must direct the CSA to not initiate any or to suspend all further case activities.
However, when the CSA's activities, without the member's participation are reasonably anticipated to not result in physical or emotional harm, the IM agency must:
First notify the person of the determination and the proposed directive to the CSA to proceed without his or her participation.
He or she has ten days from the notification date to:
Exclude allowable individuals, or
Request a hearing, or
Withdraw the application, or request that the case be closed.
At the end of the ten days, direct the CSA to proceed if no option was taken. The CSA may decide to not proceed based on its own assessment.
The IM agency determination to proceed without the member's participation must be in writing. Include your findings and the basis for the determination. File it in the case record.
When good cause is not granted, the IM agency must notify the parent or caretaker. It must be stated in the notice that he or she has ten days from the notification date to:
Cooperate, or
Exclude allowable individuals, or
Request a hearing, or
Withdraw the application or request that the case be closed.
When the ten days have expired, and if none of the options listed above has been taken, the IM agency must deny Medicaid to the applicant or terminate the member’s Medicaid eligibility. The sanctions remain in effect until there is cooperation or until it is no longer an issue.
The IM agency does not have to review determinations based on permanent circumstances. Review good cause determinations that were based on circumstances subject to change when there is new evidence or at redeterminations.
The parent or caretaker must be notified when it is determined that good cause no longer exists. It must be stated in the notice that he or she has ten days from the notification date to:
Cooperate, or
Exclude allowable individuals, or
Request that the case be closed, or
Request a hearing.
When the ten days have expired, and if none options listed above has been taken, the IM agency must deny the individual’s Medicaid eligibility. The sanctions remain in effect until there is cooperation or until it is no longer an issue.
This page last updated in Release Number: 08-01
Release Date: 02/01/08
Effective Date: 02/01/08
The information concerning the Medicaid program provided in this handbook release is published in accordance with: Titles XI and XIX of the Social Security Act; Parts 430 through 481 of Title 42 of the Code of Federal Regulations; Chapters 46 and 49 of the Wisconsin Statutes; and Chapters HA 3, DHS 2, 10 and 101 through 109 of the Wisconsin Administrative Code.
Notice: The content within this manual is the sole responsibility of the State of Wisconsin's Department of Health Services (DHS). This site will link to sites outside of DHS where appropriate. DHS is in no way responsible for the content of sites outside of DHS.
Publication Number: P-10030