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Wisconsin Department of Health and Family Services Obsolete Medicaid Eligibility Handbook For the current MEH, see http://www.emhandbooks.wi.gov/meh-ebd/ For the current BC Plus Handbook, see http://www.emhandbooks.wi.gov/bcplus/ |
Any parent or other caretaker relative who applies for or receives MA and who refuses to cooperate in establishing paternity and obtaining medical support may claim good cause. S/he must:
Specify the circumstance that is the basis for good cause, and
Corroborate the circumstance according to the evidence requirements in 3.3.5.5.
The IM agency or Social Service agency must issue a Good Cause Notice ( DES 2018 ) to all clients whenever a child is added to the MA card. The notice describes the right to refuse to cooperate for good cause in establishing paternity and securing medical support.
The IM worker and the client must sign and date the notice. File the original in the case record and give the client a copy. The CSA refers anyone who wants to claim good cause back to you.
Give a Good Cause Claim form ( DWSW 2019 ) to any MA client who requests one. It describes the circumstances that support a claim and how to document a claim.
The client must sign and date the claim in the presence of an IM worker or a notary public. The client’s signature initiates the claim.
File the original in the case record, give the client a copy, and attach a copy to the referral document when a claim is made at application.
Send the CSA a copy of all other claims within two days after a claim is signed. When you inform the CSA of a claim, they will immediately suspend all activities to establish paternity or secure medical support until notified of your final determination.
The IM agency or Social Service agency must determine whether or not cooperation is against the best interests of the child. They waive cooperation only if:
The client’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
Client. This means the impairment is of such a nature or degree that it reduces that person's capacity to adequately care for the child, or
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 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.
The IM agency or Social Services staff must determine whether or not there is good cause. This should be done within 45 days from the date a claim is signed. You may extend this if it is documented in the case record that additional time is necessary because:
The CSA cannot obtain the information needed to verify the claim within the 45 days, or
The client does not submit corroborative evidence within 20 days.
File the good cause determination and all evidence submitted in the case record. Include a statement on how the determination was reached.
If there is no evidence or verifiable information available that suggests otherwise, you must conclude that an alleged refusal to cooperate was, in fact, a case of cooperation to the fullest extent possible.
If the client is cooperating in furnishing evidence and information, do not deny, delay, or discontinue MA pending the determination.
If a Fair Hearing is requested on a good cause determination, continue any MA certification until the decision is given.
Do not use the 45-day period for determining good cause to extend an eligibility determination. The 30-day limit on processing an application is still a requirement.
The IM agency must notify the applicant 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.
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 putative father or absent parent might inflict physical or emotional harm on the client or the child.
Medical records which give the emotional health history and present emotional health status of the client or the child.
A written statement from a mental health professional indicating a diagnosis of or prognosis on the emotional health of the client 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 client 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 client, 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 client submits only one piece of evidence or inclusive evidence, you may refer him/her to a mental health professional for a report relating to the claim.
When a claim is based on his/her undocumented statement that the child was conceived as a result of incest or sexual assault, you may review it 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 client has 20 days, from the date the claim is signed, to submit evidence. The IM or social services staff may, with supervisory approval, determine that more time is needed.
There must be at least one document of evidence, in addition to any sworn statements from the client.
Encourage the provision of as many types of evidence as possible and offer your assistance in obtaining necessary evidence.
When insufficient evidence has been submitted:
Notify the client of this and specify the evidence needed, and
Advise that person on how to obtain the evidence, and
Make a reasonable effort to obtain specific documents that are not reasonably obtainable without assistance.
If the client continues to refuse to cooperate or the evidence is still insufficient, notify him/her of this. State in the notice that if no further action is taken within ten days from the notification date, good cause will not be found and that s/he 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.
When the ten days have expired and no option above has been taken:
Deny MA to the applicant or remove the recipient from the MA card, and
Provide MA without regard to the client's needs, to the eligible child(ren).
The sanctions remain in effect until there is cooperation or until it is no longer an issue.
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 found when both the client's statement and the investigation satisfy you that s/he has good cause.
You may investigate any claim when the client'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 putative father without first notifying the client of your intention. You must also notify him/her and s/he 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 hearing.
When the ten days have expired and no option has been taken:
Deny MA to the applicant or remove the recipient from the MA card, and
Provide MA, without regard to the client's needs, to the eligible child(ren).
The sanctions shall remain in effect until there is cooperation or until it is no longer an issue.
When good cause is found, the IM agency must direct the CSA to not initiate any or to suspend all further case activities.
However, when the CSA's activities, without the client'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/her participation.
S/he has ten days from the notification date to:
a. Exclude allowable individuals, or
b. Request a hearing, or
c. 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's determination to proceed without the client'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 found, the IM agency must notify the client. Also state in the notice that s/he 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 no option has been taken:
Deny MA to the applicant or remove the recipient from the MA card, and
Provide MA, without regard to the applicant or recipient's needs, to the eligible child(ren).
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 those based on circumstances subject to change at review and when there is new evidence.
Notify the recipient when you determine that good cause no longer exists. Also state in the notice that s/he 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 no option has been taken:
Remove the recipient from the MA card, and
Provide MA, without regard to the recipient's need, to the eligible child(ren).
The sanctions remain in effect until there is cooperation or until it is no longer an issue.
This page last updated in Release Number : 02-04
Release Date: 10/01/02
Effective Date: 10/01/02
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