County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Notice of Action NOA Number Page 4171 1 of 4 Revision Date June 1 2019 A Background A NOA notifies applicants of the eligibility determination for an application for MediCal benefits A NOA also informs beneficiaries of changes in their eligibility status level of benefits share of cost SOC or no change in MediCal eligibility or level of benefits at annual redetermination or a change in circumstances redetermination Purpose This section is updated to include the policy for NOAs at annual redetermination or a change in circumstances redetermination when there is no change in eligibility or benefit level B Policy1 Adequate NOA An adequate NOA must contain the following Notify beneficiaries of their MediCal eligibility ineligibility and of any changes in their eligibility status SOC or no change in eligibility or level of benefits at the annual redetermination or a change in circumstances redetermination Notify applicants of the workers decision regarding their application Be on a form prescribed by the Department of Health Care Services DHCS Include the name and telephone number of the worker who completed the eligibility determination Include the date the form was completed Have a copy kept in the case file Include the approval denial or discontinuance of eligibility the rescission of a denial or discontinuance the change in SOC and the effective date of the action Include the amount of the SOC if any and the amount of the net nonexempt income used to determine the SOC only applies to NOAs regarding SOC Include a statement of what action the worker intends to take or has taken Include the reasons an action is being taken and the law or regulations that require the action if the action is a denial discontinuance increase in SOC or reduction in level of benefits fullscope to restricted Include the applicantbeneficiarys right to request a State hearing For cases specifically tied to a lawsuit or change in law explain the circumstances under which a hearing will be granted Include the procedures for requesting a State hearing and the time limits in which a State hearing must be requested Inform applicants that they may represent themselves or use legal counsel a relative friend or other spokesperson Include the circumstances under which aid will be continued if a State hearing is requested Include a statement regarding any information or action necessary to reestablish eligibility or determine a correct SOC Include GEN 1365 or MC 4034 to inform the applicantbeneficiary of translation services if they do not understand English County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Notice of Action NOA Number Page 4171 2 of 4 2 Timely NOA With an adequate NOA notify beneficiaries of an action taken to discontinue benefits increase the SOC or reduce the level of benefits at least 10 days prior to the first of the month in which the action becomes effective except as noted below 3 Timely Notice Not Required Discontinuance You do not have to give the beneficiary 10day notice of the discontinuance due to any of the following reasons The beneficiary is deceased The whereabouts of the beneficiary is unknown and County mail sent to the beneficiary was returned by the Post Office indicating no known forwarding address The beneficiary was admitted to an institution which results in ineligibility of the beneficiary refer to Article 6 to determine the effect on eligibility The beneficiary also receives MediCal under another identity or category or in another county or state or will have dual eligibility on the first of the coming month if discontinuance action is not taken The beneficiary gives a signed statement which requests the discontinuance of the case or gives information that requires discontinuance and includes an acknowledgement by the beneficiary that providing the information will result in discontinuance of benefits The beneficiary has a new address that indicates outofstate residence 4 Timely Notice Not Required SOC Increase You do not have to give the beneficiary 10day notice when the SOC is increased for either of the following reasons The beneficiary voluntarily adds an eligible family member who is not currently receiving benefits under any MediCal program The beneficiary provides a signed statement which gives information that requires an increase in the SOC and includes an acknowledgement by the beneficiary that providing this information will result in an increase in the SOC 5 Notices for Mentally Incompetent Individuals For mentally incompetent individuals who have a public guardian conservator or representative acting on their behalf the NOA will be sent to that individual instead of the incompetent applicant beneficiary If requested by the applicantbeneficiaryAuthorized Representative AR a copy of the NOA will be sent to the administrator of the longterm care facility where the applicantbeneficiary resides 6 Notices to ARs ARs may receive a copy of a specific NOA at the request of the applicantbeneficiary 427 However the AR must receive all NOAs in relation to a State hearing without the need for the applicantbeneficiary to request it 7 Requirements for MediCal NOAs at Annual Redetermination or Change in Circumstances Where There Is No Change in Eligibility or Level of Benefits Send a NOA to MAGI and nonMAGI MediCal beneficiaries in the following circumstances At annual redetermination when there is no change in the eligibility status or level of benefits County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Notice of Action NOA Number Page 4171 3 of 4 Following a change in circumstances redetermination that results in the resetting of the annual redetermination date when there is no change in the eligibility status or level of benefits C Procedure 1 Automated NOAs Run Eligibility Determination and Benefit Calculation EDBC or use Print a NOA Manually subsystem in CalWIN to generate a NOA The print vendor automatically includes the GEN 1365 or MC 4034 for NOAs that are printed in the batch process If printing immediately include a shelf stock GEN 1365 or MC 4034 with the NOA 2 Multiple NOAs Do not send multiple simultaneous NOAs for programs for which the applicantbeneficiary is ineligible Clear the print queue after running EDBC to remove the NOAs for every program for which the applicantbeneficiary does not qualify and send the NOA for the program for which the applicant beneficiary does qualify 3 Notices for Minor Consent Give a NOA to a child applying for Minor Consent services in the FRC at the end of the interview or eligibility determination If the interview was completed off site the Minor Consent applicant must go to the FRC to pick up the NOA Use the MC 239V for these situations The MC 239V has the appropriate sections preprinted on the form Advise the applicantbeneficiary to read and destroy the NOA if confidentiality may be compromised 4 Rescinding NOAs If you issue a NOA to either discontinue or deny a case based on anticipated ineligibility and the ineligibility does not occur the NOA is no longer valid and must be rescinded Send a NOA to notify the applicantbeneficiary that the action to discontinue or deny has been rescinded Program Impacts None References 42 CFR 431206b13 431210ad 431211 431213 435912 435916 and 435919 Welfare and Institutions Code Section 1400537 22 CCR 50179ad MPP 22001 and 22022 MEPM 4U ACWDLs 0832 1313 1418 1432 and 1903 MEDIL I 1524 MPG Letters 812 and 813 Sunset Date This policy will be reviewed for continuance by June 30 2022 County of San Diego Health and Human Services Agency HHSAMediCal Program Guide Notice of Action NOA Number Page 4171 4 of 4 A Rick Wanne Director Eligibility Operations