Adverse Action Overview

Adverse Actions are taken when there is:

    • a decrease in benefits
    • the participant/HH is no longer eligible
    • the participant/HH has failed to cooperate

 

Adverse actions could affect individual participants or the entire household. When a change in circumstances occurs on an active case the information is either entered in evidence on the Integrated Case. In certain instances, the system will start the adverse action automatically.

 

If the change requires verification of evidence, the 31A wizard must be used. There can be changes which result in no pending verification of evidence (see note) and in these cases, the 31A wizard must be used and the information requested using the free form text.

 

If there is no response to the 31A after 10 days, the system starts the Adverse Action process and sends the 80PRE/80 and 33C in the appropriate timeframes.

 

If information is received from the 31A, follow the Adverse Action with Pending Evidence Verifications.

 

NOTE: Examples of 31A’s that would not have pending evidence in MEDES, in which the case should close for Non-Cooperation: Clarification of household composition, member relationships, and asking if the customer has insurance available.

 

 

 

NOTE: ONLY DELETE NOTICES WITH SUPERVISORY APPROVAL

    1. Make all necessary Evidence changes
        1. Update evidence using all applicable user guides
    2. Complete all verifications

 

IF THERE ARE STILL ITEMS ON THE DASHBOARD PENDING VERIFICATION:

    1. Follow steps to Generate a Request for Information
        1. The System will generate an M80, 33C and extended eligibility evidence (EEE) on the dashboard.
        2. The system will then send the queued notices on the scheduled days. The system will update and create new EEE evidence as needed if no verifications or CIC changes are entered for a new determination.
    2. Follow the steps found in ADVERSE ACTION WITH PENDING EVIDENCE VERIFICATIONS

 

IF THERE ARE NOT ITEMS ON THE DASHBOARD PENDING VERIFICATION, BUT YOU STILL NEED TO VERIFY INFORMATION:

    1. Follow steps to Generate a Request for Information
        1. The System will generate an IM80, 33C and extended eligibility evidence (EEE) on the dashboard.
    2. If the verification is a CS-201:
        1. Follow Steps found in ADVERSE ACTION AND CS-201
    3. If the verification is for: clarification of household composition, member relationships, or asking if the participant has insurance available:
        1. Follow Steps found in ADVERSE ACTION WITH NON-PENDING EVIDENCE VERIFICATIONS