RFP 240000001827 - Attachment I - Action Notices.docx

Long Term Supports and Services (LTSS)

Adequate Action Notice Level of Care Determination (LOCD) Verification Review

Date

Name Address

Dear {beneficiary name}:

Following a Verification Review of your long-term support and service needs, it has been determined that you do not qualify for nursing facility level services based on the Michigan Medicaid Nursing Facility Level of Care Determination (LOCD). You did not qualify under any of the following eligibility categories: Activities of Daily Living, Cognition, Physician Involvement, Treatments and Conditions, Skilled Rehabilitative Therapies, Behavior, or Service Dependencies. The legal basis for this decision is 42 CFR 440.230(d).

If you do not agree with this action, you may request a Medicaid Fair Hearing: To request a Medicaid Fair Hearing, complete a “Request for Fair Hearing” form and return it in the enclosed pre-addressed envelope, or mail it to:

Michigan Administrative Hearing System Michigan Licensing and Regulatory Affairs P.O. Box 30763 Lansing, MI 48909

The Medicaid Fair Hearing Request must be:

· Received within 90 calendar days of the date of this notice

· In writing, and

· Signed by you or a person authorized to sign for you.

Sincerely, {Reviewer Representative}

Enclosures:

Hearing Request Form Return Envelope cc: L. Alisyn Crawford Esq., MPH MDHHS

Long Term Supports and Services (LTSS)

Advance Action Notice Level of Care Determination (LOCD) Secondary Review Date

Name Address

Dear {beneficiary name}:

Following a Secondary Review of your long-term support and service needs, it has been determined that you do not qualify for nursing facility level services based on the Michigan Medicaid Nursing Facility Level of Care Determination (LOCD). You did not qualify under any of the following eligibility categories: Activities of Daily Living, Cognition, Physician Involvement, Treatments and Conditions, Skilled Rehabilitative Therapies, Behavior, Service Dependencies, or Exception Criteria. The legal basis for this decision is 42 CFR 440.230(d).

If you do not agree with this action, you may request a Medicaid Fair Hearing: To request a Medicaid Fair Hearing, complete a “Request for Fair Hearing” form and return it in the enclosed pre-addressed envelope, or mail it to:

Michigan Administrative Hearing System Michigan Licensing and Regulatory Affairs P.O. Box 30763 Lansing, MI 48909

The Medicaid Fair Hearing Request must be:

· Received within 90 calendar days of the date of this notice

· In writing, and

· Signed by you or a person authorized to sign for you.

Sincerely, {Reviewer Representative}

Enclosures:

Hearing Request Form Return Envelope cc: L. Alisyn Crawford Esq., MPH MDHHS