Current through Register Vol. 50, No. 9, September 20, 2024
A. Every
applicant for, and enrollee of, Medicaid Program benefits has the right to
appeal an agency action or decision, and has the right to request a fair
hearing in the presence of an impartial hearing officer.
1.
Action-a termination,
suspension or reduction of Medicaid eligibility or covered services. This
includes terminations by skilled nursing facilities and nursing facilities to
transfer or discharge residents and adverse determinations made by a state
(Medicaid Program) with regard to the preadmission screening and annual
resident review requirements of §1917(e)(7) of the Social Security
Act.
2. Exception. Enrollees are
not entitled to a fair hearing if the sole issue is a federal or state law
requiring an automatic change adversely affecting some or all Medicaid
recipients.
3. Applicants and
enrollees shall be informed in writing of the right to request a fair hearing
and of the procedure to do so.
B. The Medicaid Program may delegate the
responsibility for conducting fair hearings to another state agency. Any agency
with delegated authority to conduct fair hearings on behalf of the Medicaid
Program shall comply with the federal notice and fair hearing requirements
pursuant to 42 CFR 431, subpart E, and all other Medicaid Program and state
regulations governing fair hearings.
C. Applicants and enrollees must request a
fair hearing within 30 days of the date of the adequate and/or timely decision
notice issued by the Medicaid Program or its designee.
D. Maintenance of Services Pending a Fair
Hearing Request
1. If the Medicaid Program
sends a notice to the recipient as required under
42 CFR 431.211 or
§
431.214,
and the recipient requests a hearing before the date of action, the recipients
services will not be terminated or reduced by the Medicaid Program until a
decision is rendered after the hearing unless:
a. it is determined at the hearing that the
sole issue is one of federal or state law or policy; and
b. the recipient is promptly informed by
Medicaid, in writing, that the services are to be terminated or reduced pending
the hearing decision.
2.
If the Medicaid Programs action is sustained by the hearing decision, recovery
procedures may be instituted against the applicant/recipient to recoup the cost
of any services furnished, to the extent they were furnished solely by reason
of this §101 D
AUTHORITY NOTE:
Promulgated in accordance with
R.S.
36:254 and Title XIX of the Social Security
Act.
