Notification of Planned Action Instructions



|[pic] |Instructions for |

|Office of Developmental Disabilities Services |Notification of Planned Action |

A Notification of Planned Action must comply with Oregon Administrative Rule

(OAR) 411-318-0020.

Table of Contents

Definitions 2

Instructions 2

Dates, individual’s information, and contact person 3

Planned action 4

Reason for action 4

Relevant Oregon Administrative Rule(s) 4

Records used in the decision 5

Notice of hearing rights 5

Part 1 — How does an individual request a hearing? 5

Part 2 — What are the individual’s hearing rights? 6

Part 3 — How can the individual continue to receive benefits/services during their hearing? 6

Part 4 — Can an individual request to have a hearing within five working days? 7

What to do if an individual contacts you about the Notification 7

When to use a notification of planned action

A Notification of Planned Action must be sent to each individual if: (1) an application for DD services is denied; (2) a request for a new service or provider is denied; (3) a request for an increase in services is denied; or (4) if the individual’s existing services will be reduced, terminated or suspended for any reason. Use the following definitions and step-by-step instructions to complete the Notification.

Definitions

A denial notice is a written rejection of a new application for developmental disability services, a request for an increase to an existing service, or a request for a new provider or new type of service.

A reduction notice reduces existing services, but it does not terminate the entire service or services. For example, a reduction notice is sent when the allowable service hours are reduced because a new assessment indicates the individual needs a fewer number of support hours, or the individual voluntarily requests to have fewer services reflected on a plan.

A suspension notice suspends the existing services until further notice. This notice temporarily stops services, but it does not terminate services indefinitely. A suspension notice is sent if an individual is not available to receive services, or if the individual must take an action before being able to receive a service.

A termination notice stops an existing service or services. A termination notice is sent when an individual is no longer eligible for services or Title XIX Medicaid benefits.

A voluntary reduction, suspension or termination of services occurs when an individual remains eligible for services, but requests a CIIS, Brokerage or CDDP to either close their file or amend their plan to show a reduction or suspension of services. A Notification of Planned Action should not be issued if a plan includes services that an individual chooses not to use in a given month or plan year; in that case, the actual plan is not changed and the individual could still choose to use the service.

An amended notice changes or corrects something on a previously issued notice, such as the effective date of planned action, the OAR citations or the reason for action. An amended notice must include a current date of notice and an updated effective date of planned action, following OAR 411-318-0020. A new Notification of Planned Action should not be issued if a rescission is necessary. If the planned action will change, a letter should be issued to rescind the incorrect Notification of Planned Action.

Instructions

Please complete Pages 1 and 2. The contact name and phone number entered on Page 1 will be automatically entered in Part 1 when you print the form.

Dates, individual’s information, and contact person

Date of notice

Write the date that the Notification of Planned Action is being sent or hand delivered.

Amended Notice

If the notice will amend a previously issued Notification of Planned Action (to clarify or correct the actual notice, change the effective date of action, add OAR clarification, or another amendment other than rescission of the planned action), select the drop-down option directly under the top right section under the title, ‘Notification of Planned Action’. Select ‘This Notice amends a previous notice’. If the Notice is original and not amended, do not select this item and leave the box blank.

Effective date of planned action

Denial of services

For denials, the ‘effective date of planned action’ is the same as the ‘date of notice'.

Reduction, termination or suspension of services

a) If the Notification is being sent on or before the 18th of the calendar month, the effective date of action should be the last day of the same calendar month.

b) If the Notification is being sent on or after the 19th of the calendar month, the effective date of action should be the last day of the next calendar month.

Individual’s name

Write the full legal name of the individual that applied for services, or the individual that was previously found eligible and is currently receiving services. If the individual is a minor or has a legal guardian, you may add the legal guardian as a c/o, but the rest of the Notification should be written to the individual.

Individual’s date of birth

Write the date of birth of the individual.

Street address

Write the individual’s mailing address.

Notifying agency

Write the official name of your CDDP, Brokerage or CIIS Program.

Notification completed by

From the drop-down menu, select your position at the CDDP, Brokerage or CIIS.

This person should complete the form and be able to answer questions related to

the Notification, if contacted. The person listed here must be able to answer questions about the notice of hearing rights and know how to fill out the Administrative Hearing

Request Form. Typically, this should be the eligibility specialist, services coordinator, or personal agent; use the other line if you hold a different position

Name and phone number

List the name and phone number of the caseworker, services coordinator, personal agent, eligibility specialist, or other CDDP, Brokerage or DHS employee completing the form. This name and phone number will be automatically filled into Part 1 when you print the document.

Planned action

Denials

The first two rows in the table are for denials.

• Check the box in the first row if it is a denial of an application for services.

• Check the box in the second row if it is a denial of a specific request for a new service or provider, or a request for an increase in services, and write-in the specific request.

Reductions, suspensions, terminations (including voluntary reductions, suspensions and terminations)

Check the box in the third row before ‘your services are going to be’ and select the appropriate option from the menu: reduced; suspended; terminated; voluntarily reduced; voluntarily suspended; or voluntarily terminated. Second, identify the specific services that will be reduced, suspended or terminated.

Reason for action

Clearly state the reason for the action and specifically describe the tools used to make the determination. For example, if an individual’s services are being reduced as a result of a new assessment, you would write: “your monthly service level of attendant care (ADL/IADL) hours are being reduced from 33 hours per month to 30 hours per month based on the completion of the functional needs assessment completed on April 12th, 2014.”

Relevant Oregon Administrative Rule(s)

Include the specific OARs and section of the OARs that support the planned action. If more than one section applies, make sure to use ‘&’ or ‘and’ in between the rule sections you list. (Example from the scenario above (based on OARs in effect 12/31/13 to 06/30/14): 411-308-0020(33); 411-308-0020(45); 411-308-0070(1) & 411-308-0080(1) and (2). Only cite the rule number; do not write the rule text. As a courtesy, you can attach the rule text as a separate document for the individual or their representative to review).

Records used in the decision

It is the individual’s right to know what documents you reviewed and used to make the decision. Write the individual’s name, date of birth and age, and then list each document you used to deny, reduce, suspend, or terminate the service(s).

In the table include the:

1. Date of the record/report/evaluation;

2. Type of the record/report/evaluation; and

3. Author of the evaluation/report/document.

All documents must be identified on each Notification of Planned Action.

Example documents are: needs assessments, annual plans, Supplemental Support documents, psychological evaluations, medical records, progress notes, or other anecdotal information. It is not necessary to identify the actual data or information contained within the documents.

Notice of hearing rights

The Notice of Hearing Rights provides basic information to individuals and families about their rights and how to proceed if they want to contest the planned action, or if they believe they were treated unfairly or differently. The Notice also informs the individual that they can contact you for an informal discussion (see the instructions below on what to do if you are contacted about the Notification) and it informs military personnel where to get information.

The introduction contains general information, including a note for military personnel on active duty. Parts 1 – 4 contain information about:

1. How to request a hearing;

2. Where to find more information and who can assist and represent individuals;

3. How to make a request to continue the current level of services; and

4. How to request a hearing within five working days.

Part 1 — How does an individual request a hearing?

Part 1 lists three ways an individual can request a hearing. If an individual is dissatisfied with the action being taken, they have the right to request an administrative hearing.

Your name and number (entered on page one) will auto-fill in Part 1 when this form is printed so the individual can contact you to verbally request a hearing and discuss the decision. See the instructions below if someone contacts you about this Notification or makes a verbal request for a hearing.

Who can request a hearing?

1. The individual whose services are denied, reduced, suspended or terminated; or

2. Any adult, such as a parent, family member, legal representative, guardian or advocate, chosen by an individual to represent the individual in connection with the provision of developmental disability services or during the complaint or hearing process. The representative may not be an employee acting in official capacity for the Department, CDDP or Brokerage. An individual is not required to choose a representative.

Late hearing requests

Requests must generally be received within 90 days of the date of notice on the Notification; however, late hearing requests are considered under certain circumstances. The DHS hearing representatives or the Administrative Law Judge (ALJ) will determine whether or not to accept a late hearing request. You may assist the individual with a late hearing request by asking them for the reason they were unable to request a hearing within the timelines outlined on the back of the notice. This is not intended to be challenging, but is just an opportunity to get more information. Make sure you let them know that you will submit the hearing request form, which includes the reason that they were not able to submit a timely request, and that DHS or the ALJ will determine whether there is a sufficient reason to accept the late hearing request.

Part 2 — What are the individual’s hearing rights?

ORS chapter 183 and OAR 411-318-0025 give an individual the right to request a hearing if they do not agree with the planned action. At the hearing, the individual can explain why they do not agree with the decision, and they can have people testify on their behalf. The laws about hearing rights and the hearing process are contained in OAR 137-003-0501 through 137-003-0700 and ORS chapter 183. See the information below for a brief summary of the next steps. If an individual requests a hearing, a hearing representative from the Department of Human Services will contact them to schedule an informal conference.

OAR 137-003-0555 permits individuals to appoint a representative to dispute the decision. Individuals may also be able to get free legal services from Disability Rights Oregon (1-800-452-1694), Legal Aid Services of Oregon (1-800-520-5292) or the Oregon State Bar (1-800-452-8260).

If individuals do not request a hearing on time, withdraw a hearing request, or do not appear at a hearing, they may lose the right to a hearing. If there is no hearing, the Notification of Planned Action becomes DHS’s final decision (called a “Final Order by Default”) and the individual will not receive a separate Final Order by Default. DHS refers to the case file, along with any materials submitted in this matter, as “the record.” The record is used to support the Final Order by Default.

Part 3 — How can the individual continue to receive benefits/services during their hearing?

OAR 411-320-0025 states an individual may request that their services remain the same if services are being terminated, reduced or suspended; AND the individual asks for a hearing; AND they wish to continue receiving services pending a final order. DHS refers to this as Continuing Services or Aid Paid Pending.

Under OAR 411-318-0025, individuals can request continuing services by requesting a hearing before the effective date of planned action. This can be done by:

1. Verbally notifying the CDDP, Brokerage, CIIS or DHS;

2. Writing an email or letter to the CDDP, Brokerage, CIIS, or DHS; or

3. Checking the “yes” box on the Administrative Hearing Request Form (SDS 0443DD).

Individuals may also receive continuing services if the individual requests a hearing and continuing services within 10 business days after the effective date of planned action.

Part 4 — Can an individual request to have a hearing within five working days?

Individuals may have the right to an “expedited hearing” if the individual is denied a medical service that creates an immediate, serious threat to their life or health, or if there was a denial of a request to continue to receive services until a hearing. The individual must request an expedited hearing on the Administrative Hearing Request

Form (SDS 0443DD).

What to do if an individual contacts you about the Notification

If you are contacted about the Notification, inform the individual about information in the Notice of Hearing Rights and Parts 1 – 4, and follow these steps:

1. Discuss the reason that you issued the Notification of Planned Action.

2. Avoid discouraging the individual from requesting a hearing. Avoid speculating about the potential decision of an Administrative Law Judge (ALJ). Do not persuade or suggest individuals to reconsider a decision to request a hearing.

3. If the individual or their representative is dissatisfied with the planned action, let them know that they can choose to have an ALJ review the individual’s file and DHS’s Notification of Planned Action. Inform the individual that the hearing will take place by conference phone, unless the individual requests a hearing in-person.

4. If an individual provides additional information in response to the Notification of Planned Action (that was not available when the Notification was issued), communicate with ODDS to determine the next steps.

If an individual or their representative tells you that they want to have a hearing

1. Ask the individual or representative if they would like to complete the Administrative Hearing Request Form (SDS 0443DD), or if they would like you

to complete the Administrative Hearing Request Form (SDS 0443DD).

2. If the individual or representative would like to complete the form and submit it

to DHS, promptly send the form.

3. If you are asked to complete the Administrative Hearing Request Form

(SDS 0443DD), fill out the form:

• List the reason for requesting a hearing;

• Sign the form as the person who has completed the form;

• Mail a copy of the document to the individual or representative;

• Keep a copy of the document in the individual’s case file;

• Send the original document to the address on the back form; and

• Make a progress note of the hearing request and conversation, as well as the actions that you took as a result of the individual’s hearing request.

Hearing Process — What happens next?

Once DHS receives the Administrative Hearing Request Form (SDS 0443DD), a Hearing Representative will be in touch with the contact on the Notification of Planned Action (this will most commonly be the caseworker) to receive the documents that supported the decision. The hearing representative will also contact the individual to schedule an informal conference to discuss the planned action and reason for denial, reduction, suspension or termination. The informal conference is an opportunity for DHS (and the CDDP, Brokerage or CIIS) and the individual to share additional information. The informal conference provides the parties the opportunity to reach a resolution before the case goes the ALJ.

At the conclusion of the informal conference, one of three things will occur:

1. The parties will proceed to a formal hearing. If the dispute is going to proceed to a hearing, the hearing representative will refer the case to the Office of Administrative Hearings (OAH). The OAH assigns an ALJ to conduct a contested case hearing. The OAH will schedule a hearing for approximately 4 weeks later and the proceedings will be conducted pursuant to OAR 137-003-0501 to 137-003-0700.

2. The individual withdraws their request for a hearing. If the individual or their representative withdraws their request for a hearing, a dismissal order is issued and the decision on the Notification of Planned Action stands.

3. DHS withdraws the Notification of Planned Action. If DHS withdraws the Notification of Planned Action, the planned action identified in the Notification is no longer valid and will not be effective on the date of planned action.

During the hearing process, the Hearing Representative will be the main contact for the individual or their representative for all matters directly related to the hearing issue.

DHS will coordinate with the DD Enrollment Unit and the ODDS Contracts Unit regarding the coding on individuals that receive continuing services during the

hearing process.

Upon receipt of the Final Order or Orders of withdrawl or dismissal, DHS will communicate with the eligibility specialist or caseworker on any required next steps.

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