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Home and Community Based Services Manual

5.00 Adverse Actions

Home and Community Based Services Manual


5.00 Adverse Actions

Introduction

Home and Community Based Service (HCBS) participants and applicants are required to receive written notice from the Division of Senior and Disability (DSDS) staff when an action adversely affects certain HCBS referrals or currently authorized services. HCBS participants and applicants have the right to appeal an adverse action.

DSDS staff shall send an Adverse Action Notice to provide notice when an action:

  • Denies initial request for HCBS
  • Denies care plan change request
  • Reduces the current authorization of HCBS
  • Closure of partial/complete HCBS

A reduction, denial or closure of HCBS is not considered an adverse action when a HCBS participant or applicant is in agreement. DSDS staff shall thoroughly document agreements in the electronic case record.

Purpose

The purpose of this policy is to:

  • Provide guidance to DSDS staff on how to process adverse actions
  • Provide guidance on different adverse action situations
  • Provide timeframes for sending adverse actions
  • Provide timeframes for how long an HCBS participant or applicant can appeal

Process

Within three (3) business days of an identified need for an adverse action, DSDS staff shall mail an Adverse Action Notice explaining all the services affected and reason(s) for the adverse action, including the Legal References for the Adverse Action [NEEDS LINK] to be taken.

Anyone may make the initial request for a hearing on the participant’s behalf. However, the participant and/or their legal guardian must be contacted directly to confirm the request. If DSDS staff cannot reach the participant and/or legal guardian by the third attempt (Appeal and Hearing Process [NEEDS LINK]), the hearing request shall not be processed, and the adverse action will proceed as appropriate.

When the participant contacts DSDS staff verbally or in writing to request a hearing, DSDS staff shall complete the Application for State Hearing Form with information provided by the participant (Appeal and Hearing Process [NEEDS LINK]).

All forms and documents related to the adverse action process shall be uploaded to the participant’s electronic case record.

Pursuant to the Code of Federal Regulations (CFR), specifically 42 CFR 431.211 regarding advance notice of an adverse action, unless otherwise specified, any adverse action that results in a change to the case status or changes to a prior authorization shall require a ten (10) calendar day notification prior to the date of the change or closing.

  • The ten (10) calendar day period begins the day after mailing the Adverse Action Notice and ends the morning of the eleventh (11) calendar day

When a participant contacts DSDS staff in response to an Adverse Action or Waiting List Notice for Independent Living Waiver (ILW) Services [NEEDS LINK], DSDS staff may need to make adjustments to the participant’s proposed care plan based on new information provided.

  • A new Adverse Action may be required in situations including, but not limited to:
    • When the proposed amount of current HCBS is increased, but not to the level requested by the participant
    • If additional HCBS are denied
    • If the proposed care plan is further decreased

In these cases, DSDS staff shall mail a Reversal of Adverse Action Form for the original action.

The participant has ninety (90) calendar days from the date the Adverse Action Notice is mailed to appeal the decision.

However, the participant must appeal within ten (10) calendar days of the date the Adverse Action Notice was mailed in order to continue receiving current services.

Note: If the appeal is ruled in favor of DSDS, the participant and/or the participant’s estate may be liable for the cost of HCBS delivered during the appeal process. DSDS staff shall notify the participant of possible liability.

The participant’s decision to continue or discontinue HCBS shall be communicated to the provider and thoroughly documented in case notes in the participant’s electronic case record.

Ineligible Due to MO Healthnet Benefits

Adverse action as a result of ineligibility for Medicaid benefits is subject to appeal initiated through the Department of Social Services (DSS), Family Support Division (FSD). This includes participants who become enrolled in a Medicaid managed care plan.

  • In such cases, the participant shall be notified by completing the Notice of Closure for HCBS Form.
  • The Notice of Closure for HCBS Form shall be mailed within one (1) business day of receipt of information of ineligibility.
  • This action does not require a ten (10) calendar day waiting period.

Assessment Level of Care Ineligibility

An Adverse Action Notice shall be sent when a potential or current participant does not meet the minimum required LOC score for the provision of HCBS.

Note: An Adverse Action Notice shall be mailed, even if the individual is in agreement with the LOC ineligibility determination.

Exceptions to the Ten Day Notification

DSDS staff shall mail the Adverse Action Notice to the last known address in the following situations, without having to wait ten (10) calendar days before processing the action, when:

  • The participant does not meet Level of Care (LOC) during an initial assessment
  • The participant is admitted to an institution where HCBS may not be continued
  • The participant has moved to another state and is no longer eligible to receive Medicaid benefits in Missouri
  • The whereabouts of the participant is unknown (e.g., mail returned by the Post Office indicates no known forwarding address)

Note: An Adverse Action Notice does not need to be mailed to the last known address if factual notification of the participant’s death is received.

ILW Waiting List

Participants placed on the Independent Living Waiver (ILW) Waiting List [NEEDS LINK] have the right to appeal their placement on the list.

  • These participants shall be notified by sending the Waiting List Notice for ILW Services [NEEDS LINK]. This action does not require a ten (10) calendar day waiting period
  • The participant has ninety (90) calendar days from the date the Waiting List Notice for ILW Services is mailed to appeal

Participant Demonstrating Threatening or Abusive Behavior

When a participant, or a member of the participant’s household, demonstrates threatening and/or abusive behavior towards a provider or other DSDS staff, the provider may request to discontinue services. DSDS staff and supervisors shall consult with DSDS Management for approval to proceed with the adverse action. The case record shall be reviewed to ensure documentation supports the action taken to discontinue the service authorization, and the participant’s failure to comply with Participant Rights and Responsibilities.

Participants Not Requesting a Hearing

All affected HCBS shall be reduced or closed as appropriate. DSDS staff shall complete necessary actions for the reduction or discontinuation.

  • DSDS staff shall notify the HCBS provider of the action taken
  • DSDS staff shall document actions taken in the participant’s electronic case record
  • No further action is necessary for participants placed on the ILW Waiting List

State Designee

The selection of State Designee shall be used when there is no HCBS provider available. The Prior Authorization shall only remain in State Designee status for ninety (90) days. State Designee is not to be selected if the participant and/or legal guardian fail to select an HCBS provider.

  • If an HCBS provider does not become available within ninety (90) days, DSDS staff shall initiate an adverse action.
  • The justification of “No Provider Selected or Available” shall be used.
  • If there is no response from the participant and/or legal guardian within ten (10) calendar days of the date of the adverse action, DSDS staff shall end date the State Designee Prior Authorization and close the case.
  • If within ninety (90) calendar days of mailing the adverse action, DSDS staff is notified by the participant and/or legal guardian that an HCBS provider has been selected, DSDS staff shall reopen the case and authorize HCBS.

Note: The case shall be reopened and HCBS authorized only if an assessment has been completed within ninety (90) calendar days of the adverse action being sent. An assessment is required if one has not been completed within 90 calendar days of the adverse action being sent.

Table of Contents

On this page

    5.00 Appendix 1 Legal References for Adverse Action

    Home and Community Based Services Manual


    5.00 Adverse Actions

    Action Taken

    • Your request for Medicaid Home and Community Based Services has been denied.
    • Your Medicaid Home and Community Based Services are being closed.
    • Your Medicaid Home and Community Based Services care plan has been reduced.
    • Your request for a change in your Medicaid Home and Community Based Services care plan has been denied.
    • Your request to participate in the Money Follows the Person Demonstration program has been denied.

    Explanation / Authority

    Table of Contents

    On this page

      5.00 Appendix 3 Adverse Action Notice

      Home and Community Based Services Manual


      5.00 Adverse Actions

      The Adverse Action Notice for Home and Community Based Services (HCBS-12) provides the current or potential participant and/or their authorized representative (e.g. guardian or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of denials (i.e. of an initial request, request for increase, or additional services), reductions, or closings of services. This notice shall be used for all adverse actions, except those due to loss of Medicaid benefits or a participant’s number on the Independent Living Waiver (ILW) Waiting List as outlined in the Adverse Action policy.

      INSTRUCTIONS 

      The HCBS electronic case record system will generate the adverse action form, which will include the following: 

      • Participant Information
        • Current or potential participant’s name
        • DCN
        • Address
        • Phone number (Include an extension number if appropriate) 

      NOTE: For current or potential participants with a guardian, ensure the guardian’s contact information is included on the form. • 

      • Choose the appropriate “Action Taken” and any applicable “Explanation/Authority” from the Legal References for Adverse Action
        • It may be appropriate to select more than one category from the “Explanation/Authority” section in certain cases.
        • Certain categories for Consumer-Directed Services contain a list of reasons for the adverse action.
      • Date of Change
        • The date shall be the day the change will take place
        • This date shall be the eleventh (11th) day from the date the notice is mailed unless noted otherwise as outlined in the Adverse Action policy
      • Hearing Request
        • The date in both fields shall be when the participant must request a hearing to continue receiving HCBS at the current level.
        • This date shall be the tenth (10th) day from the date the notice is mailed as outlined in the Adverse Action policy.
      • DSDS Staff Information
        • DSDS staff’s name
        • Signature
        • Phone number (Including an extension number as appropriate and mailing address)
        • The date the notice is mailed 

      DISTRIBUTION 

      Upon completion, the original HCBS-12 shall be mailed to the current or potential participant and/or their authorized representative. A copy is also maintained in the participant’s electronic case record. When a hearing is requested for Medicaid funded services, a copy of the HCBS-12 shall be included in the exhibit packet sent to the Department of Social Services (DSS), Division of Legal Services (DLS).

      Table of Contents

      On this page

        5.00 Appendix 4 Adverse Action Notice

        Home and Community Based Services Manual


        5.00 Adverse Actions

        The Adverse Action Notice for Home and Community Based Services (HCBS-12) provides the current or potential participant and/or their authorized representative (e.g. guardian or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of denials (i.e. of an initial request, request for increase, or additional services), reductions, or closings of services. This notice shall be used for all adverse actions, except those due to loss of Medicaid benefits or a participant’s number on the Independent Living Waiver (ILW) Waiting List as outlined in the Adverse Action policy.

        INSTRUCTIONS 

        The HCBS electronic case record system will generate the adverse action form, which will include the following: 

        • Participant Information
          • Current or potential participant’s name
          • DCN
          • Address
          • Phone number (Include an extension number if appropriate) 

        NOTE: For current or potential participants with a guardian, ensure the guardian’s contact information is included on the form.

        • Choose the appropriate “Action Taken” and any applicable “Explanation/Authority” from the Legal References for Adverse Action
          • It may be appropriate to select more than one category from the “Explanation/Authority” section in certain cases.
          • Certain categories for Consumer-Directed Services contain a list of reasons for the adverse action.
        • Date of Change
          • The date shall be the day the change will take place
          • This date shall be the eleventh (11th) day from the date the notice is mailed unless noted otherwise as outlined in the Adverse Action policy
        • Hearing Request
          • The date in both fields shall be when the participant must request a hearing to continue receiving HCBS at the current level.
          • This date shall be the tenth (10th) day from the date the notice is mailed as outlined in the Adverse Action policy.
        • DSDS Staff Information
          • DSDS staff’s name
          • Signature
          • Phone number (Including an extension number as appropriate and mailing address)
          • The date the notice is mailed 

        DISTRIBUTION 

        Upon completion, the original HCBS-12 shall be mailed to the current or potential participant and/or their authorized representative. A copy is also maintained in the participant’s electronic case record. When a hearing is requested for Medicaid funded services, a copy of the HCBS-12 shall be included in the exhibit packet sent to the Department of Social Services (DSS), Division of Legal Services (DLS).

         

        Table of Contents

        On this page

          5.00 Appendix 4 Application for the State Hearing

          Home and Community Based Services Manual


          5.00 Adverse Actions

          The Application for State Hearing for Home and Community Based Services allows the current or potential participant and/or their authorized representative (e.g. guardian or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information Form that is in effect) an opportunity to appeal an adverse action taken in regard to denials (i.e., of an initial request of HCBS, request for increase or additional services), reductions, or closings of services. 

          This application shall be used to confirm a request for an official hearing for all Home and Community Based Services (HCBS) authorized by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS). 

          The Application for a State Hearing for HCBS shall be completed by DSDS using information provided by the participant.

          NOTE: The Application for a State Hearing for HCBS may be completed by the participant upon request

          INSTRUCTIONS 

          DSDS staff shall enter the following information in the appropriate fields: 

          • Applicant Information
            • Applicant’s Name
            • DCN
            • County
            • Address
            • Phone number (include extension if appropriate)
          • Name of applicant requesting the hearing
          • Reason for the hearing request
          • Authorized Representative Information, when applicable
            • Name
            • Phone number (include extension if appropriate)
            • Address 

          NOTE: The participant may name anyone as their authorized representative; however, the Authorization for Disclosure of Consumer Medical/Health Information Form shall be completed prior to the release of protected health information (PHI) 

          • Indicate whether the participant requested to continue receiving services at the current level. If selection is not made, services shall remain authorized
          • This does not apply to participants appealing their number on the Independent Living Waiver (ILW) Waiting List
          • Applicant’s signature and date, when completed by the participant
            • Indicate in the signature field if the request is made via phone
          • Indicate if the hearing request is based on a denial, discontinuance, or reduction
            • This does not apply to participants appealing their number on the ILW Waiting List
          • Date the hearing was requested
          • Reason for the planned action or decision, including the legal reference for the decision
          • List service(s) being adversely affected
          • DSDS Staff Information
            • Name
            • Phone number (include extension when appropriate)
            • Address
          • DSDS staff shall forward the form to their immediate supervisor for review within three (3) business days.
          • Division of Legal Services Information (completed by DLS)
            • Date received by DLS
            • Assigned DLS Hearings Officer 

          SUPERVISOR RESPONSIBILITIES 

          • Review the request and confirm validity within three (3) business days
          • Sign the form
          • Submit this form along with the Adverse Action form and the Agency Witness List to the DSDS HCBS Hearings Representative

           NOTE: Supervisor may, at their discretion, request additional collateral contacts be made to further verify validity. This additional contact should not exceed three (3) additional business days. 

          HCBS HEARINGS REPRESENTATIVE RESPONSIBILITIES 

          • Submit the exhibits packet to the Regional Administrative Hearings Office
          • Enter the date sent to DLS
          • Send the exhibit packet ten (10) business days prior to the hearing to the Participant, DSDS staff and supervisor 

          NOTE: The Exhibits packet may be delayed if additional information is required.

           

          DISTRIBUTION 

          • A copy shall be mailed to the participant and/or their authorized representative, when necessary
          • A copy is maintained in the participant’s electronic case record

          Table of Contents

          On this page

            5.00 Appendix 5 Reversal of Adverse Action Notice

            Home and Community Based Services Manual


            5.00 Adverse Actions

            The Reversal of Adverse Action Notice form for Home and Community Based Services (HCBS) shall be utilized to notify current or potential participants and/or authorized representatives (e.g., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) that the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS) has reversed its previous decision regarding an adverse action. The Department of Social Services (DSS), Division of Legal Services (DLS), and the DSDS HCBS Hearings Representative shall also be notified of the reversal when necessary.

            INSTRUCTIONS 

            DSDS staff shall enter the following information in the appropriate fields: 

            • Current or potential participant Information
              • Name
              • DCN
              • Date notice is being mailed
              • Address
              • Phone number (include extension when appropriate) 

            NOTE: When the current or potential participant has a guardian, the guardian's information shall be entered in this section. 

            • Check the appropriate box or boxes regarding the original adverse action.
            • Check the box in the last section ONLY when reversing an adverse action that has been submitted to DLS
            • Enter the address of the appropriate Regional Administrative Office.
            • DSDS staff information
              • Signature and
              • Printed name
              • Phone number (include extension when appropriate)
              • Address 

            DISTRIBUTION 

            • The original form shall be mailed to the participant and/or their authorized representative.
            • A copy is maintained in the participant’s electronic case record. 

            NOTE: If a hearing request has already been forwarded to DLS, a copy of the Reversal of Adverse Action Notice shall be mailed to the appropriate DLS Regional Office and DSDS HCBS Hearings Representative.

            Table of Contents

            On this page

              5.00 Appendix 6 Notice of Closure

              Home and Community Based Services Manual


              5.00 Adverse Actions

              The Notice of Closure form for Home and Community Based Services (HCBS) provides current participants and/or their authorized representative (i.e., guardian, or someone with a signed Authorization for Disclosure of Consumer Medical/Health Information that is in effect) with written notification of the closing of currently authorized services. This notice shall only be used for HCBS closed by the Department of Health and Senior Services (DHSS), Division of Senior and Disability Services (DSDS), due to the participant’s loss of Medicaid benefits covering the authorization of HCBS or when participants are enrolled in a Managed Care Health Plan. 

              DSDS shall mail this notice no later than the date the action is taken. 

              If the participant wants to request an appeal, they must contact the Department of Social Services (DSS), Family Support Division (FSD). 

              INSTRUCTIONS 

              DSDS staff shall enter the following information in the appropriate fields: 

              • Participant information
                • Name
                • DCN
                • Address
                • Phone (include extension when appropriate) 

              NOTE: When the participant has a guardian, the guardian’s information shall be entered in this section. 

              • Select the appropriate checkbox.
              • Check the first box when services must close based upon FSD’s determination that the participant is not eligible for Medicaid benefits or the participant’s Medicaid Eligibility (ME) [NEEDS LINK] code does not include DSDS HCBS benefits.
                • Check the second box when the participant has been enrolled in Managed Care and choose the appropriate drop-down selections based on the participant’s Managed Care Organization.
              • Enter the date the change will take place. This is the date of mailing
              • DSDS staff information
                • Signature
                • Printed Name
                • Address
                • Date
                • Phone (include extension when appropriate)

              DISTRIBUTION 

              • The original shall be mailed to the participant and/or their authorized representative
              • A copy is maintained in the participant’s electronic case record

              Table of Contents

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