State of Wisconsin Department of Health Services

HISTORY

The policy on this page is from a previous version of the handbook. 

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22-01 Version of 23.1 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, patient liability, or cost share amount.

23.1.1 Notice Requirements

Applicants and members must be provided with 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

23.1.2 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 which 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

23.1.2.1 Notice of Denial

Any notice of denial of 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

23.1.3 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.

23.1.3.1 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 of the income maintenance agency to contact for more information

23.1.4 Timely Notice of Adverse Action

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.

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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