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LTC Notice of Action Operational Memo
A new Operational Memo will be developed that will supersede the PHE Memo that went out in 2020 regarding Notice of Actions (NOA)s (HCPF OM-045 Eligibility and Notice of Action Changes). The purpose of this Operational Memo will be to inform Single Entry Points (SEPs), Community Centered Boards (CCBs) and Case Management Agencies (CMAs) of operational changes to case management requirements for issuing a Notice of Action (LTC-803) for a member’s functional eligibility. At this time, a Level of Care Eligibility Approved Notice of Action should be sent for Initial assessments only, and do not need to be completed for annual Continued Stay Review Level of Care assessments unless the member no longer meets Level of Care.
Notice of Action forms in the Care and Case Management System
At this time, the Merge and Send feature in the CCM for Notice of Action letters should not be used. Please do not attempt to use the CCM in order to mail out Notice of Action letters until notified by HCPF. Notice of Action letters are currently posted on the Long-Term Services and Supports Case Management Forms and Tools Page. Please continue to use the LTSS CM Tools Webpage link to ensure that the NOA letter you are using is the most up to date.
Member Certification Period
Case Management Agencies should continue to ensure that an LTC Notice of Action is completed and sent to the member if a Continued Stay Review/Person-Centered Service Plan is not completed within a minimum of eleven (11) days prior to the end of the current Certification Period. This includes when a county or eligibility site has not verified financial eligibility. The LTC Notice of Action sent by a Case Management Agency in this circumstance is not a Notice of Action regarding the member’s financial eligibility, but rather, is a Notice of Action to inform the member that their Person-Centered Support Plan is not completed before the end of their current certification period.
Appeals
Case managers should verify that a member has filed an appeal with the Office of Administrative Courts for the adverse action which will allow the member to continue receiving services as approved in their previous Person-Centered Service Plan through the appeal period. No changes in services may be made for the Person-Centered Service Plan for a member through an appeal period; the Person-Centered Service Plan must be entered exactly as it was in the previous certification period.
CMAs should also be aware that if a member has been notified via a Notice of Action from the county or eligibility site that they are no longer eligible for Health First Colorado benefits and they file an appeal with the Office of Administrative Courts, they are also eligible to continue receiving services as previously approved in their Person-Centered Service Plan through an appeal period. Case managers should verify that a member has filed an appeal with the Office of Administrative Courts for the adverse action which will allow the member to continue receiving services as approved in their previous Person-Centered Service Plan through the appeal period. No changes in services may be made for the Person-Centered Service Plan for a member through an appeal period; the Person-Centered Service Plan must be entered exactly as it was the previous certification period.
In the event that a member receives a Notice of Action, that member has the right to appeal the action that is outlined in their Notice of Action letter. If a member is receiving services, and appeals an action before their services are set to end or decrease, they may continue to receive their waiver services until a final decision is made on their appeal. The member must ask their case manager for their services to continue within 10 calendar days from the date on their NOA letter, or before their services are scheduled to end.
In order for a member to request continued coverage in CBMS, the member must first notify their case manager within 10 calendar days of the date on their Notice of Action letter that they would like their services to continue. The member must also follow instructions on their Notice of Action letter and return it to the Office of Administrative Courts to initiate the appeal process. After the appeal has been received and initiated, HCPF eligibility and appeals staff add a continuation of benefits in CBMS which allows member to remain locked into their LTC coding until a determination is made on their appeal. This allows members to continue receiving their state plan benefits and services throughout the appeal period. Case managers should submit a County and Eligibility Site Member Complaint and Escalation Webform to notify HCPF that they have received verification that a member has filed an appeal with the Office of Administrative Courts and HCPF level manual override is necessary to activate LTC Medicaid so a Person-Centered Service Plan can be entered in the InterChange.
In the event that a member requests to continue receiving services during their appeal period, they may do so. Regardless of the outcome of the appeal hearing, the member will not be responsible for “paying back” any of the funds that were allocated to their services during that appeal period. Any language regarding the need to “pay back” services if a member does not “win” their appeal has been removed from all up-to-date Notice of Action templates.
Level of Care and PMIPs
Please do not complete a Notice of Action regarding an Initial Level of Care assessment until (1) the LOC 100.2 assessment has been completed, and (2) a completed Professional Medical Information Page (PMIP) has been obtained by the Case Management Agency. We want to prevent unnecessary appeals or escalations in which the member is notified that they meet or do not meet Level of Care requirements prior to both of these steps being completed.
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