(1) Upon an adverse action by the department affecting benefits administered by the department, including but not limited to Temporary Assistance for Needy Families (TANF), food stamps, Medicaid, LIEAP, LIWAP, refugee assistance, and daycare benefits, the claimant shall be provided adequate and timely notice.
(a) This rule applies only to adverse actions against claimants;
(b) Notice and hearing rights of providers are governed by ARM 37.5.307; and
(c) This rule shall not be construed to require notice to a claimant when the department provides notice to a provider.
(2) If the adverse action proposed by the department is the suspension, reduction or termination of benefits of the claimant, notice is timely if it is mailed at least ten days prior to the time the proposed adverse action is to become effective.
(3) Adequate notice need not be provided prior to the date of adverse action but may be mailed at the time the adverse action is taken in the following instances:
(a) the department has factual information of death of claimant or payee (and no relative is available to serve as payee) or of all members of the household if claimant is a household for purposes of the Food Stamp program;
(b) claimant provides a signed written statement requesting termination or reduction of benefits;
(c) when the fact that claimant has been accepted for benefits in another jurisdiction has been established, except that for purposes of the Food Stamp program the department need only establish that claimant has moved from the project area;
(d) when claimant was notified in writing that benefits would automatically terminate at the time that the grant for or the certification of benefits was made, including a special allowance for a specific period, benefits received to restore lost benefits, and benefits provided pending approval of benefits under another program; and
(e) in the case of benefits received under the Food Stamp program as follows:
(i) the claimant's allotment varies from month to month within the certification period to account for anticipated change and the claimant was so notified at the time of certification;
(ii) claimant or member of claimant household is subject to a lockout or strike and signs a waiver of notice of adverse action to allow the department to reduce or terminate benefits when the claimant or member of claimant household receives income from employment again;
(iii) a member of claimant household is disqualified for fraud, or the benefits of the claimant household are reduced or terminated to reflect the disqualification of the member as provided for in 7 CFR 273.16; and
(iv) the department initiates a mass change as described in 7 CFR 273.12(e).
(f) in the case of benefits received under all programs except the Food Stamp program:
(i) the claimant enters an institution and further benefits do not qualify for federal financial participation;
(ii) claimant is placed in skilled or intermediate nursing care or long-term hospitalization;
(iii) claimant's whereabouts are unknown and mail is returned with no forwarding address;
(iv) claimant is a child receiving benefits under the TANF program and is removed from his home by judicial determination or is voluntarily placed in foster care by legal guardian;
(v) a change in claimant's medical care is prescribed by his physician; and
(vi) claimant has provided information which requires termination or reduction of assistance and has indicated in writing that he understands the consequences of providing the information.
(4) In the case of probable fraud in all programs except the Food Stamp program, notice of adverse action is timely if mailed at least five days prior to the effective date of the adverse action.
(5) Notice is adequate if it includes:
(a) a statement of the proposed adverse action;
(b) the reason for the proposed adverse action;
(c) the specific regulations supporting the proposed adverse action;
(d) a statement of the claimant's right to a hearing;
(e) how to obtain a hearing;
(f) telephone number to call for additional information;
(g) the right to be represented by legal counsel, friend, relative or other spokesman;
(h) the availability of free legal assistance if such assistance is known to the department program manager involved in the denial of the claim;
(i) if applicable, whether or not benefits are to be continued and the liability of the claimant for benefits received pending hearing if the hearing decision is adverse; and
(j) any other information as specifically required by applicable law, including department rule.
(6) A notice is effective for purposes of this rule if the notice substantially complies with the requirements of (5). A notice shall not be considered inadequate for purposes of this rule based upon good faith errors or omissions that are not prejudicial to the substantial rights of the claimant.
(7) A claimant is not entitled to advance notice of an adverse determination regarding medical necessity of services under the Medicaid program. The department may review medical necessity as provided in ARM 37.85.410 and notice of any adverse action may be provided within a reasonable time after a determination, even though the services may have been provided at an earlier date.