Code of Maryland Regulations
Title 14 - INDEPENDENT AGENCIES
Subtitle 35 - MARYLAND HEALTH BENEFIT EXCHANGE
Chapter 14.35.11 - Fair Hearings of Individual Exchange Eligibility Determinations
Section 14.35.11.09 - Findings, Timing of Decision, and Effect of Decision
Universal Citation: MD Code Reg 14.35.11.09
Current through Register Vol. 51, No. 6, March 22, 2024
A. Findings.
(1) The administrative law judge shall:
(a) Prepare a written summary of findings and conclusions based exclusively on the record; and
(b) Make a decision based on his findings and conclusions.
(2) The summary of findings and conclusions shall:
(a) State the evidence, policies, regulations, or laws upon which the administrative law judge's decision is based; and
(b) Provide written notice to the appellant that, if they are not satisfied with the decision, they may seek additional appeals as specified in §C of this regulation.
B. Timing of Hearing Decision.
(1) The administrative law judge shall forward to the appellant, and to appellant's authorized representative, if applicable, a copy of the findings, conclusions, and decision within 90 days from the date the appellant or appellant's representative filed a request for a fair hearing pursuant to Regulation .05A of this chapter.
(2) If the date of the fair hearing is postponed at the appellant's request, the length of the postponement may not be counted as part of any of the time period specified in §B(1) of this regulation.
C. Appeal Rights.
(1) Any party may seek judicial review as provided in State Government Article, §
10-222, Annotated Code of Maryland.
(2) An administrative law judge's decision:
(a) Related to Program benefits:
(1) Shall be implemented immediately, if adverse to the appellant.
(2) If favorable to the appellant, shall be implemented retroactively to the date the incorrect action was taken; or
(b) Related to eligibility for enrollment in a qualified health plan, advance payments of the premium tax credit, cost-sharing reductions, or State-based subsidies shall be implemented in accordance with 45 CFR §
155.545(c)(1).
(3) To the extent an administrative law judge's decision upholds the determination or redetermination of the Exchange with respect to an applicant for eligibility for enrollment in a qualified health plan or for an insurance affordability program described in Regulation .02B(10)(d) or (e), the applicant may appeal to the United States Department of Health and Human Services pursuant to 45 CFR §
155.520(c).
D. Effect of Decision.
(1) When the decision requires action by the Department, the Exchange shall notify the Department.
(2) When the decision is favorable to the appellant, or when the Exchange grants the appellant the relief the appellant requests before the decision, the Exchange, where applicable, shall authorize corrected payments or relief retroactive to the date the incorrect action was taken and redetermine eligibility for household members whose eligibility may be affected by the appeals decision.
(3) Any payment or action by the Exchange under §D(2) of this regulation may not constitute a waiver of the Exchange's sovereign immunity from suit.
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