Section 29-9508. NOTICE AND FAIR HEARING RIGHTS

 

9508.1 The Department shall provide timely and adequate notice of eligibility and enrollment determinations and the right to appeal to Medicaid applicants and beneficiaries consistent with the requirements set forth in Federal and District law and rules.

 

9508.2 The Department shall provide timely and adequate notice to Medicaid applicants and beneficiaries in cases of intended adverse action such as an action to deny, discontinue, terminate, or change the manner or form of Medicaid services.

 

9508.3 An adequate notice shall include:

 

(a) A statement of what action(s) are intended;

 

(b) The reason(s) for the intended action(s);

 

(c) Specific law and regulations supporting the action, or the change in federal or District law that requires the action(s);

 

(d) An explanation of an applicant or beneficiary’s right to request an administrative or fair hearing; and

 

(e) The circumstances under which Medicaid is provided during the pendency of a hearing.

 

9508.4 A timely notice shall be postmarked at least fifteen (15) calendar days before the date an action would become effective, except as permitted under Subsection 9508.5.

 

9508.5 The Department may dispense with timely notice, but shall send adequate notice under the following circumstances:

 

(a) The Department has factual information confirming the death of a beneficiary;

 

(b) The Department receives a written and signed statement from a beneficiary:

 

(1) Stating that Medicaid is no longer required; or

 

(2) Providing information which requires termination or reduction of Medicaid and indicating, in writing, that a beneficiary understands the consequence of supplying the information;

 

(c) A beneficiary has been admitted or committed to an institution, and no longer qualifies for Medicaid;

 

(d) A beneficiary’s whereabouts are unknown and Department mailings, directed to the beneficiary, has been returned by the post office indicating no known forwarding address;

 

(e) A beneficiary has been deemed eligible for Medicaid in another state and that fact has been established;

 

(f) A change in level of medical care has been prescribed by a physician;

 

(g) Presumptive eligibility granted for a specific period is terminated and the beneficiary has been informed in writing at the time of application that the eligibility automatically terminates at the end of the specified period;

 

(h) The notice involves an adverse determination made with regard to the preadmission screening requirements of Section 1919(e)(7) of the Act; or

 

(i) The date of action will occur in less than ten (10) days, in accordance with 42 C.F.R. Section 483.12(a)(5)(ii), which provides exceptions to the thirty (30) day notice requirements of 42 C.F.R. Section 483.12(a)(5)(i).

 

9508.6 Under the circumstances identified in Subsection 9508.5, the Department shall issue notice no later than the effective date of action.

 

9508.7 The Department may issue a notice no later than five (5) calendar days before the date of action if the Department has facts related to probable fraud by the beneficiary; and those facts have been verified, if possible, through secondary sources.

 

9508.8 Applicants and beneficiaries may request, through any of the means described at Subsection 9508.12, an administrative review of an adverse action from the Department of Human Services, Economic Security Administration before requesting a fair hearing.  A request for an administrative review shall not affect the right to request a fair hearing.

 

9508.9 The Department shall grant an opportunity for a fair hearing when:

 

(a) An application for Medicaid is denied;

 

(b) Eligibility for Medicaid is suspended;

 

(c) Eligibility for Medicaid is terminated;

 

(d) An applicant or beneficiary believes the Department has taken an action which affects the receipt, termination, amount, kind, or conditions of Medicaid in error;

 

(e) A beneficiary, who is a resident of a skilled nursing facility, believes the Department has wrongly determined that a transfer or discharge from the facility is required;

 

(f) A beneficiary believes the Department made a wrong determination with regard to the preadmission and annual resident review requirements of Section 1919(e)(7) of the Social Security Act (the Act);

 

(g) A beneficiary, who is an enrollee in a Managed Care Organization (MCO) or Pre-paid Inpatient Health Plan (PIHP), was denied coverage of or payment for medical services; 

 

(h) A beneficiary who is dissatisfied with the District’s determination that disenrollment from a MCO, PIHP, Pre-paid Ambulatory Health Plan, or Primary Care Case Management is appropriate; or

 

(i) A Medicaid claim was denied or not acted upon with reasonable promptness pursuant to D.C. Official Code Section 4-210.02 and Subsection 9501.9.

 

9508.10 The Department shall not be required to grant a hearing if the sole issue is a federal or District law requiring an automatic change that adversely affects some or all beneficiaries.

 

9508.11 The Department may deny or dismiss a request for a fair hearing if:

 

(a) The applicant or beneficiary withdraws the request in writing; or

 

(b) The applicant or beneficiary fails to appear at a scheduled hearing without good cause.

 

9508.12 An individual, an adult who is in the individual’s household, or an authorized representative shall submit a fair hearing request via:

 

(a) Internet;

 

(b) Telephone;

 

(c) Mail;

 

(d) In person; or

 

(e) Through other commonly available electronic means.

 

9508.13 An applicant or beneficiary seeking a fair hearing shall submit a fair hearing request no later than ninety (90) days following the date the notice of adverse action is mailed.

 

9508.14 Where the Department provides notice as required under Subsections 9508.3 through 9508.7, and the beneficiary requests a fair hearing before the date of adverse action, the Department may not terminate or reduce services until a hearing decision is rendered unless:

 

(a) It is determined at the hearing that the sole issue is one of Federal or District law or policy; and

 

(b) The Department promptly informs the beneficiary in writing that Medicaid services will be terminated or reduced pending the hearing decision.

 

9508.15 The Department may reinstate Medicaid services if a beneficiary requests a hearing not more than ten (10) days after the date of action.

 

9508.16 Reinstated services shall continue until a hearing decision is reached unless, the hearing has determined that the sole issue is one of federal or District law or policy.

 

9508.17 The Department shall reinstate and continue services until a decision is rendered after a hearing if:

 

(a) Action is taken without the advance notice required under Subsections 9508.5 through 9508.7;

 

(b) The beneficiary requests a hearing within ten (10) days from the date that the individual receives the notice of action. The date on which the notice is received is considered to be five (5) days after the date on the notice, unless the beneficiary shows that notice was not received within the five (5)-day period; or

 

(c) The Department determines that the action resulted from other than the application of federal or District law or policy.

 

9508.18 If a beneficiary's whereabouts are determined to be unknown, discontinued services shall be reinstated if the beneficiary’s whereabouts become known during the time the beneficiary is eligible for services.

 

9508.19 The Department shall allow an applicant or beneficiary who requests a fair hearing decision no later than fifteen (15) days of the date that notice is mailed to decline receipt of Medicaid pending a fair hearing decision.

9508.20 An appeal to the District Health Benefits Exchange Authority of a determination of eligibility for advanced payments of the premium tax credit or cost-sharing reduction shall trigger a request for a fair hearing under this section.

 

9508.21 Fair hearings and appeals for the District Medicaid  program shall be administered through the Office of Administrative Hearings in accordance with 42 C.F.R. Section 431.10(d) and 42 C.F.R. Sections 431.200 et seq., and amendments thereto, 1 DCMR Section 2970 through 1 DCMR Section 2978, and amendments thereto, and D.C. Official Code Sections 4-210.01 et seq., and amendments thereto.

 

9508.22 This section shall apply to all eligibility determinations for Medicaid programs administered by the Department of Health Care Finance under Title XIX and Title XXI of the Act.

 

 

authority

An Act to enable the District of Columbia (District) to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat.774; D.C. Official Code § 1-307.02 (2014 Repl.)), and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)).

source

Final Rulemaking published at 62 DCR 11142 (August 14, 2015).