Current through Register Vol. 35, No. 18, September 24, 2024
Unless stayed by court order, the department's final fair
hearing decision is binding on all issues that have been the subject of the
fair hearing as to that claimant. The local county office is responsible for
assuring that decisions are implemented within the timeframes specified below.
The final fair hearing decision serves as advanced notice for changes in
benefits or services.
A.
Decision favorable to the department: If assistance or benefits
have been continued pending the outcome of the fair hearing and the decision is
favorable to the department, the department shall take immediate action to
adjust the payment and submit a claim for the excess benefit amount(s) paid
pending the outcome of the fair hearing.
B.
Decision favorable to the
claimant:
(1)
Cash assistance
programs: When a fair hearing decision is favorable to the claimant, the
department authorizes corrective payment. For incorrectly denied cases,
corrected benefits are issued retroactively in the following manner:
(a) to the date of adverse action or to the
30th day from the application date, whichever is earlier; or
(b) to the first day of the month that the
case is actually eligible for benefits;
(c) for ongoing cases, the corrected cash
assistance payments are retroactive to the first day of the month that the
incorrect action became effective.
(2)
SNAP: Decisions that result
in an increased benefit shall be reflected in the claimant's next authorized
allotment. The final fair hearing decision serves as verification for increased
benefits.
(3)
Medical
assistance programs: When a fair hearing decision is favorable to the
claimant and a case was incorrectly denied, corrected benefits are issued
retroactively in the following manner:
(a) to
the date of adverse action or to the 30th day from the application date,
whichever is earlier; or
(b) to the
first day of the month that the case is actually eligible for
benefits;
(c) for ongoing cases,
the corrected benefit is retroactive to the first day of the month that the
incorrect action became effective;
(d) fair hearings for medical assistance
programs involving the termination, modification, reduction or suspension of
services are governed by applicable federal and state law and regulations,
including 8.352 NMAC, et seq.
C.
Implementation of decisions related
to NMHIX: Unless stated by court order, the department's final fair
hearing decision is binding on all issues that have been the subject of the
fair hearings as to that claimant. NMHIX, upon receiving notice of the final
fair hearing decision, must promptly:
(1)
Implement the decision effective:
(a)
Prospectively, on the first day of the month following the date of the notice
of appeal decision, or consistent with
45 CFR section
155.330(f)(2), (3), (4), or
(5), if applicable; or
(b) Retroactively, to the coverage effective
date the appellant did receive or would have received if the appellant had
enrolled in coverage under incorrect eligibility determination that is the
subject of the appeal, at the option of the appellant.
(2) Redetermine the eligibility or household
members who have not appealed their own eligibility determinations but whose
eligibility may be affected by the appeal decision, in accordance with the
standards specified in
45 CFR section
155.305.
