Children’s Long-Term Support (CLTS) Waivers
March, 2006 Template for Termination Due to Policy
DATE (This date must be at least 10 calendar days before the end date in Option 1 or 2 below, taking into account mailing time, weekends and/or holidays). FAMILY NAME ADDRESS ADDRESS ADDRESS Dear NAME: This letter is to inform you that your , , no longer meets the requirements necessary to be eligible for the Children’s Long-Term Support Medicaid Home and Community-Based Services Waiver (CLTS Waiver). Specifically, COUNTY: PICK Option 1 or 2, DELETE other option. Please see “Termination of CLTS Waiver Participation)” on how to establish end dates. OPTION 1: Your child’s CLTS Waiver services and your child’s eligibility for Wisconsin Medicaid will end on: < DATE.> OPTION 2: Your child’s CLTS Waiver services will end on : < DATE. > Your Wisconsin Medicaid eligibility will continue through . You have the right to appeal this decision. You may request a county grievance by: You may also request a fair hearing by writing to the Wisconsin Division of Hearings and Appeals. The Division of Hearings and Appeals (DHA) must receive your written request no later than 45 days from the CLTS Waiver Services end date above. The hearing would take place as close as possible to your area of residence. If you request a hearing before the CLTS Waiver services end date above, you child’s services may continue if so you choose until a
PolicyRelatedTerminationLetter.doc
Children’s Long-Term Support (CLTS) Waivers
March, 2006 Template for Termination Due to Policy
hearing decision is reached; please indicate to the DHA if you want services to continue until the hearing decision is reached. Please Note: Per the Code of Federal Regulations 42 CFR §431.230, if you choose to request a hearing on this termination and the hearing decision upholds the termination, you may be required to reimburse the cost of the services provided during the period of the hearing process. The address for submitting a written hearing request is: Division of Hearings and Appeals 5005 University Avenue, Ste. 201 Madison, WI 53705-5400 If you have questions, please contact Sincerely, cc: Children’s Services Section, Department of Health and Family Services Division of Hearings and Appeals
PolicyRelatedTerminationLetter.doc
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