Current through Register Vol. 56, No. 18, September 16, 2024
(a) Upon
receipt of a timely request for a fair hearing, Medicaid coverage shall be
continued until a written decision is rendered, unless:
1. A determination is made at the hearing by
the ALJ that the sole issue is one of State or Federal law or policy, or change
in State or Federal law, and not one of disputed facts; or
2. A change occurs which further affects
beneficiary's eligibility while the first hearing decision is pending and the
beneficiary fails to request an additional hearing after notice of this change
within the time allowed.
(b) In the event of either (a)1 or 2 above,
the beneficiary shall be promptly notified in writing that the proposed action
will be implemented after the hearing while the decision is pending.
(c) Any incorrectly paid benefit resulting
from continued Medicaid coverage is subject to recovery. In the event that
agency action is sustained and a beneficiary has received incorrectly paid
Medicaid benefit, solely due to continued eligibility, recovery shall be
effected in accordance with procedures in
10:69-9.23.
(d) A beneficiary may waive his or her claim
to Medicaid by submitting a written statement at the time the fair hearing is
requested.
(e) To assure orderly
and expeditious processing of complaints and hearing requests, each CWA shall
designate a liaison between the county and State Division whose duties shall
include, but not be limited to:
1. Informing
the Bureau of Administrative Review and Appeals (BARA) by telephone on the same
day an oral or written request for a hearing is received, providing the
following information:
i. The case number and
the applicant/beneficiary's name and address;
ii. The date the request received;
iii. The nature of contested
action;
iv. The date of action;
and
v. The reason for
action;
2. Establishing
a system to assure that every written request for a hearing received in the CWA
office is stamped with the date of receipt and forwarded to BARA within one
work day of the date;
3. Reviewing
incoming requests for possible corrective action prior to hearing;
4. Identifying and arranging for
participation of staff individuals who are essential to a hearing, and
assembling all records relevant to a hearing and arranging for an interpreter
when the client is non-English speaking;
5. Contacting the applicant/beneficiary or
his or her legal or authorized representative not less than two days prior to a
hearing to confirm attendance and arranging for transportation by agency staff
and vehicles or otherwise at agency expense when no other reasonable means of
transportation is available;
6.
Submitting special reports on hearing requests prior to the hearing date, when
requested by BARA;
7. Submitting
reports on implementation of fair hearing decisions as soon as such action is
taken when requested; and
8.
Serving as the single individual in the CWA to be contacted regarding matters
relating to hearings and the monitoring system.
(f) The CWA is responsible to inform the
applicant/beneficiary who is requesting a hearing and elects to receive
continued Medicaid that the ALJ may find him or her not entitled to all or a
portion of the Medicaid coverage received during the pendency of the hearing
and that, in such event, repayment may be required of the amount of benefits
received from the effective date of the proposed adverse action to the date of
the scheduled hearing.
1. The beneficiary
shall also be advised that if he or she elects not to receive continued
Medicaid coverage and the hearing decision is favorable to the client, Medicaid
coverage shall be reinstated retroactive to when it was terminated.
