Current through Register Vol. 56, No. 18, September 16, 2024
(a) In cases of any
proposed action to terminate, reduce or suspend assistance, the Medicaid Agent
or DMAHS shall give the claimant timely and adequate notice detailing the
reasons for the proposed action. Under these requirements:
1. "Timely" means that the notice is dated at
least 10 days before the action is to be taken; and
2. "Adequate advance notice" means a written
notice that includes a statement of the action the Medicaid Agent or DMAHS
intends to take, reasons for the proposed departmental action, the specific
regulations that support, or the change in Federal or State law that requires
the action, the claimant's right to request a fair hearing, or in cases of a
departmental action based on a change in law, the circumstances under which a
hearing shall be granted, and the circumstances under which assistance shall be
continued if a fair hearing is requested.
(b) In cases in which there is a request for
a fair hearing within the advance notice period:
1. Assistance shall be continued until a
decision is rendered unless:
i. It is
determined at the hearing that the sole issue is one of Federal or State law or
policy; and
ii. The Medicaid Agent
or DMAHS promptly informs the claimant in writing that services shall be
terminated or reduced pending the hearing decision.
2. If the Medicaid Agent's or DMAHS's action
is sustained by the hearing decision, the Medicaid Agent or DMAHS may institute
recovery procedures against claimants to recoup the cost of any services
furnished claimants to the extent the services were furnished solely by reason
of this section.
(c) The
Medicaid Agent or DMAHS may reinstate services if a claimant requests a hearing
not more than 10 days after the effective date of the termination, suspension
or reduction of eligibility or covered services.
1. If services are reinstated, they shall
continue until a hearing decision is made unless it shall be determined at the
hearing that the sole issue is one of Federal or State law or policy.
(d) The Medicaid Agent or DMAHS
shall reinstate and continue services until a decision is rendered after a
hearing if:
1. An action is taken to
terminate, suspend or reduce eligibility or covered services without affording
claimants adequate advance notice as defined herein;
2. Claimants request a hearing within 10 days
of the date of the notice of action; and
3. The Medicaid Agent or DMAHS determines
that the action to terminate, reduce or suspend assistance resulted from
reasons other than the application of Federal or State law or policy.
(e) If a claimant's whereabouts
are unknown, as indicated by the return of unforwardable departmental mail
directed to them, any discontinued services shall be reinstated if their
whereabouts become known during the time they are eligible for
services.
