Notice

Number

Notice Title

Use

M001

Rights and Choices for Waiver Recipients

When authorizing Medicaid with waiver services or converting an individual from regular Medicaid coverage to waiver services.  This notice tells the recipient that he or she should contact the care coordinator or waiver managing agency if there are problems or concerns with service providers, etc.

M002

MQTMedicaid Qualifying Trust Trust Referral

When denying a Medicaid application due to excess income.  It informs the applicant that Medicaid coverage may be available through use of a Qualifying Income Trust.  It refers the denied applicant to contact Alaska Legal Services or the Alaska Bar Association if he or she wishes to investigate use of a trust.

M003

No Cost of Care Due

It is important to send this notice on LTCLong Term Care, HCBHome and Community-Based Waiver and all Nursing Home cases that currently do not have a COCCost-of-care liability.  This notice informs the recipient about COC, that the current obligation is zero, but in the future there may be an obligation.  This way if there is ever a spike in monthly income, the agency can assess a COC liability for that month the income was received.

M005

Notice to Transfer Resources to Spouse

To inform a new Medicaid recipient that he or she has one year to transfer any resources above $2000 to his or her community spouse before the next renewal date.  Failure to send this notice may result in the new recipient not completing the transfer(s) and becoming resource ineligible at the annual review.

M006

Application for Other Benefits

When an individual appears to be eligible for a benefit from another program.

M007

Request for Social Security Number

When Social Security enumeration is required by the Medicaid program.

M008

Medicare Benefits Available

When an applicant or recipient appears to be eligible for Medicare, the individual is required to enroll by the Medicaid program.

M012

Long Term Care Caseworker Introduction

When a case is transferred from a regular Medicaid caseworker to a new caseworker due to application for the HCB Waiver program or admission to an LTC facility.

M060

Child Support Cooperation Statement

When requesting cooperation with CSSDChild Support Services Division activities.

M061

Child Support -

Good Cause  Allowed

When a good cause determination IS allowed from cooperating with CSSD.

M062

Child Support - Good Cause Not Allowed

When a good cause determination is NOT allowed from cooperating with CSSD.

M100

Medicaid Approved - One Month Only

When an individual is only eligible for Medicaid during the application month.

M102

Medicaid Application Approved

When approving a Medicaid-only case.

M103

Retroactive Medicaid Approved

When applicant is Medicaid eligible in one of three months preceding month of application.

M106

Emergency Medical Treatment Approved

For approving emergency coverage for aliens.

M110

 Medicaid Approved QMBQualified Medicare Beneficiaries coverage

For approving QMB coverage to pay for Medicare Part A and Part B premiums, deductible, and coinsurance.

M111

Special Medicaid Coupon

When a disability exam or a waiver determination is needed.

M112

Medicaid Approval Waiver Services

For approving LTC Medicaid.  Explains that eligibility has been met due to being found eligible for HCB Waiver services.

M113

Specified Low Income Medicare Benefit

For approving SLMBSpecified Low Income Medicare Beneficiaries coverage to pay for Medicare Part B premiums.

M114

Medicaid Approved 2nd Month

When Medicaid eligibility begins in the 2nd month of application.

M115

Working Disabled Medicaid Approved

For approving Working Disabled Medicaid Buy-In.  Informs the individual that they may have to pay a monthly premium.

M118

Back-Dated Medicaid Approved

When an individual receives a finding of disability and Medicaid is approved for prior months.

M120

Cost of Care / LTCLong Term Care Facility

Cost of Care (COC) requires adverse action.  Send to Medicaid recipients residing in a LTCLong Term Care facility who are assessed a COCCost-of-care.  Send a copy of the notice to the facility attention: Patient Billing.

M121

Medicaid Approved LTCLong Term Care Facility

 When approving Medicaid for a resident of a LTCLong Term Care facility.

M122

CCMCChildren with Complex Medical Conditions Waiver Svcs Approved Child on DKCDenali KidCare

When approving CCMCChildren with Complex Medical Conditions Waiver Medicaid for a child who is receiving DKCDenali KidCare and does not have a disability determination from DDSDisability Determination Service.  The notice informs the parent(s) that the waiver can be approved due to DKCDenali KidCare eligibility, and encourages the parents to complete all paperwork so a DDSDisability Determination Service determination can be made.

M123

CCMCChildren with Complex Medical Conditions Waiver Services Approved

When approving Medicaid with CCMCChildren with Complex Medical Conditions Waiver services for a child who already has an approved State-only Disability Determination or is receiving SSISupplemental Security Income.  

M124

IDDIndividuals with Intellectual and Developmental Disabilities Waiver Svcs Approved Child on DKC

When approving Medicaid with IDDIndividuals with Intellectual and Developmental Disabilities Waiver services for a child who is receiving DKCDenali KidCare and does not have a disability determination from DDSDisability Determination Service.  The notice informs the parent(s) that the waiver can be approved due to DKCDenali KidCare eligibility, and encourages the parents to complete all paperwork so a DDSDisability Determination Service determination can be made.

M125

RPTCResidential Psychiatric Treatment Center Waiver Approved - Disabled Child

When approving a disabled child's eligibility for home and community-based waiver services under the Fetal Alcohol Spectrum Disorder/Residential Psychiatric Treatment Center Medicaid Demonstration Project.

M126

RPTCResidential Psychiatric Treatment Center Waiver Approved - FMFamily Medicaid/DKCDenali KidCare Child

When approving a child's eligibility for home and community-based waiver services under the Fetal Alcohol Spectrum Disorder/Residential Psychiatric Treatment Center Medicaid Demonstration Project.

M130

Cost of Care / Waiver

When an HCBHome and Community-Based Waiver recipient has a COCCost-of-care liability assessed.  It instructs the recipient to work with his or her care coordinator in determining which service providers to pay directly.  A copy of the notice should be sent to the Trustee and the care coordinator.

M131

APDDAdults with Physical Developmental Disabilities Waiver Services Approved

When approving Medicaid with APDDAdults with Physical Developmental Disabilities Waiver services.  This includes new applications and case conversions from regular APAAdult Public Assistance Medicaid.

M132

IDDIndividuals with Intellectual and Developmental Disabilities Waiver Services Approved

When approving Medicaid with IDDIndividuals with Intellectual and Developmental Disabilities Waiver services.  This includes new applications, conversions from regular APAAdult Public Assistance Medicaid, and SSISupplemental Security Income children approved for Waiver Services.

M133

ALIAlaskans Living Independently) (Formerly known as ODAOlder or Disabled Adults)Waiver Services Approved

When approving Medicaid with ALIAlaskans Living Independently) Waiver services.  This includes new applications and case conversions from regular APAAdult Public Assistance Medicaid.

M136

Breast/Cervical Cancer Medicaid Approved

For approving Breast/Cervical Cancer Medicaid.  Informs client that coverage will continue until treatment for cancer is completed.

M140

APAAdult Public Assistance Medicaid Qualified Income Trust

When approving APAAdult Public Assistance Related Medicaid due to the establishment of a Qualifying Income Trust.  

M141

Medicaid Special Needs or Pooled Trust

When any category of Medicaid is approved due to the establishment of a Special Needs or Pooled Asset Trust that has been approved by the Medicaid Policy officer.

M142

Medicaid Trust Information LTCLong Term Care

For all LTCLong Term Care Medicaid recipients who have an established Qualifying Income Trust.  Send a copy of the notice to the trustee(s).  A copy of this notice should be sent with every renewal and whenever there is a change in trustee.

M143

Special Needs or Pooled Trust Info

For all Medicaid recipients who have an established Special Needs or Pooled Trust.  Send a copy of the notice to the trustee and/or guardian. A copy of this notice should be sent with every renewal and whenever there is a change in trustee.  

M144

Miller Trust Information

For all Medicaid recipients who have established a QITQualifying Income Trust in order to qualify for regular APA Medicaid.  Send a copy of the notice to the trustee.  A copy of this notice should be sent with every renewal and whenever there is a change in trustee.

M200

Medicaid Denied Application Process

When applicant does not show up for appointment, or reschedule an appointment.

M201

Medicaid Denied Failure To Provide

When applicant does not provide requested information needed to determine eligibility.

M205

Medicaid Denied - Citizenship/Identity

When an applicant does not respond to the request for, or provide proof of citizenship or identity.

M207

Medicaid Denied Over Income

When applicant is not Medicaid eligible due to having too much income.

M208

Medicaid Denied Over Resource

When applicant is not Medicaid eligible due to being over the resource level.

M213

Medicaid Denied Other Reasons

When application is denied for other reasons (e.g., nonresident, request to withdraw application, receipt of benefits from another state, loss of contact).

M216

Medicaid Denied - No Eligible Category

When applicant does not fit into any Medicaid eligibility category.

M218

Medicaid Denied - Excess Home Equity

When an applicant is not eligible for Medicaid LTC services because the individual's home equity value is more than $500,000.

M221

Retroactive Medicaid Denied

When applicant is not eligible in any of the three months preceding the month of application.

M301

Medicaid Pended Information Needed.

When information is needed from a new application to determine eligibility.

M302

Medicaid Held for a Disability Decision

When a DDSDisability Determination Service decision is needed in order to establish eligibility.  It informs the applicant that their Medicaid application being held until the decision is received.  

M303

Incomplete Medicaid Review Info Needed

To request information needed from a review.

M304

Retro-Med Pended Information Needed

To request information needed to determine Medicaid eligible for any of the three months prior to month of application.

M305

Pend New Waiver Application

When a new waiver application is received.  It provides DSDSDivision of Senior and Disabilities Services contact information and provides a free form area to request other information.  

M306

Medicaid Residency Information Needed

When Alaska residency is questionable.

M307

Medicaid Pended - Citizen/ID Needed

When an application is received and proof of citizenship/identity is needed.

M308

Medicaid - Citizenship/ID Proof Needed

For renewals or reminders when citizenship/identity is needed.

M310

Medicaid - SLMBSpecified Low Income Medicare Beneficiaries Information Needed

For requesting information from Medicaid applicants so that an eligibility determination may be made for the Special Low Income Medicare Beneficiary (SLMBSpecified Low Income Medicare Beneficiaries and SLMBSpecified Low Income Medicare Beneficiaries Plus) categories

M320

Information Needed TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248

When pending a new TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 application.  It requests information that is specific to the TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 Medicaid category.  

M321

Pend Waiver Start - Child on DKCDenali KidCare

When pending a new waiver application for a child receiving DKCDenali KidCare, Family Medicaid, or Under 21 Medicaid.

M322

Pend TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248

Disabled Child Denied DKCDenali KidCare

For a TEFRATax Equity and Fiscal Responsibility Act, P.L. 97-248 referral when a DKCDenali KidCare case has been denied.

M323

RPTCResidential Psychiatric Treatment Center Waiver: Info needed - FM/DKC Child

When additional information is needed to determine a child's eligibility for home and community-based waiver services under the Fetal Alcohol Spectrum Disorder / Residential Psychiatric Treatment Center Medicaid Demonstration Project.

M350

Request Medical Insurance Information

When additional medical insurance exists and information is needed.

M351

Waiver and/or DDSDisability Determination Service Approval Needed

For Special LTCLong Term Care Category applicants who require DSDSDivision of Senior and Disabilities Services waiver approval and DDSDisability Determination Service approval.  It informs the applicant that their application is being processed and some of the eligibility factors are dependent on decisions from other agencies.

M401

Medicaid Closed Failure to Provide

When client has not provided requested information needed to determine eligibility.

M402

Failure to Complete Medicaid Review

Notifying recipient that case is closed due to no review received.

M407

Medicaid Closed Over Income

When countable income causes ineligibility - for timely notice of case closure.

M408

Medicaid Closed Over Resource

When countable resources causes ineligibility - for timely notice of case closure.

M410

Medicaid Review Received Case Closed

When closing Medicaid from a review for reasons that result in ineligibility.

M413

Medicaid Closes Other Reasons

When closing Medicaid for other reasons that result in ineligibility.

M418

Medicaid Closed - Excess Home Equity

When a recipient is not eligible for Medicaid LTCLong Term Care services because the individual's home equity value is more than $500,000.

M419

Medicaid Stops Client Deceased

When recipient dies.  State and Federal regulations require that we notify the family or estate of a deceased client whenever benefits stop.

M420

Breast/Cervical Cancer Medicaid Closure

For timely notice of case closure.  Gives reason case is closing.

M463

Refused Other Possible Benefits

When individual does not comply with Development of Income requirements.

M501

Erroneous Discontinuance

When benefits are resumed after closing in error.

M502

Fair Hearing Request Benefits Continue

When a recipient requests continued benefits while awaiting a fair hearing decision.  This notice informs the recipient that he or she will be responsible to repay the cost of benefits paid by Medicaid if the decision is not in their favor.

M601

Medicaid Suspended

To suspend Medicaid for one-month only if the client appears to be prospectively eligible after that month.

M701

Medicaid Benefits Change

When there is a change in the Medicaid category or waiver services.

M704

Change to Working Disabled Medicaid

When Working Disabled Buy-In eligibility is found upon ineligibility from another Medicaid category

M709

Med Benefits Stopped - CSSDChild Support Services Division

Penalty

When a penalty is placed on a caretaker relative for noncooperation with CSSDChild Support Services Division.

M710

Medicare Drug Coverage Begins

When a Medicaid applicant has Medicare, and when a recipient becomes eligible for Medicare.

M715

Cost of Care Change

Whenever there is a change in the COCCost-of-care obligation.  

M716

Long Term Care Ends Medicaid Continues

When Level-of-Care has been denied and ends HCBHome and Community-Based Waiver services but the recipient continues to be eligible for another Medicaid category.  It informs the recipient that regular Medicaid coverage will continue and that he or she will have a new caseworker.

M718

Excess Home Equity - Medicaid Changes

When LTCLong Term Care coverage ends due to the recipients home equity value is in excess of $500,000 and eligibility exists for other Medicaid coverage.

M720

Waiver Closed Living in LTCLong Term Care Facility

When a waiver services end because a recipient enters a LTCLong Term Care facility.

M721

Pend Waiver Application AP Med to Waiver

When a regular APAAdult Public Assistance Medicaid recipient is pursuing HCBHome and Community-Based waiver services.  It requests the additional items needed for waiver services.  

M723

Medicaid Transfer of Asset Declaration

For APAAdult Public Assistance Medicaid recipients who are pursuing HCBHome and Community-Based Waiver services. This is a notice version of the MED 3.

M724

Waiver Services Denied - Medicaid Cont.

When an application for HCBHome and Community-Based Waiver services is denied, but the recipient continues to be eligible for another medicaid category. It informs the recipient that regular Medicaid coverage will continue and that he or she will have a new caseworker.

M801

Medicaid Review Due

When a system generated review is not automatically sent.

M802

Medicaid Review Approved

For approving continued Medicaid benefits.

M805

SLMBSpecified Low Income Medicare Beneficiaries Medicare Review Approved

For approving SLMBSpecified Low Income Medicare Beneficiaries review.  Informs recipient that Medicaid will continue to pay for their Medicare Part B premiums.

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MC #30 (07/13)