Home and Community Based Services Manual
5.00 Appendix 6 Notice of Closure
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