Current through Reg. 49, No. 38; September 20, 2024
(a) When notice is required. A
Medicaid-eligible recipient is entitled to a notice under this subchapter any
time the department, its designee, or a managed care organization (MCO) intends
to take an action. An MCO is responsible for sending the notice to recipients
enrolled in the MCO. The department is responsible for sending notices to all
other recipients.
(b) Time of
notice. A notice of intent to take action must be mailed to the recipient by
the department, its designee or MCO no less than 30 days before the department,
its designee, or MCO intends to take an action.
(c) Content of notice. The notice required by
subsection (a) of this section must contain the following information:
(1) a statement of the action the department,
its designee, or MCO will take;
(2)
an explanation of the reasons the department, its designee, or MCO will take an
action;
(3) a reference to the
state or federal regulations which support the action the department, its
designee, or MCO will take;
(4) an
explanation of the recipient's right to request a fair hearing from the
department;
(5) the procedure by
which the recipient may request a fair hearing from the department or through
the MCO, including the address where written requests must be submitted and any
toll-free or local phone number the recipient may call to request assistance or
a fair hearing;
(6) an explanation
that recipients may represent themselves or have legal counsel, a relative, a
friend, or another spokesperson represent them;
(7) an explanation of whether and under what
circumstances services may be continued if a fair hearing is
requested;
(8) a statement that the
recipient must make a request for a fair hearing within 30 days from the date
on the notice, and that if the recipient does not request a fair hearing within
this time period, the recipient's right to a fair hearing will be waived. The
notice is presumed to be received by the recipient five days from the date of
the notice;
(9) an explanation that
the recipient may request the fair hearing be conducted based on written
information without the necessity of taking oral testimony. The written
information may consist of the department's records, the medical information
submitted by the recipient, and any additional written information the
recipient may wish to submit; and
(10) a notice from an MCO informing
recipients of their right to access the department's fair hearing process under
§ 36.23 of this title (relating to Fair Hearings).
(d) Resolution prior to fair hearing. The
department will make every effort to informally resolve the action before the
fair hearing date.
(e) Emergency
Procedure.
(1) Actions relating to
emergencies will be handled by the department on an expedited basis.
(2) The department, its designee or the MCO
will give the recipient notice of their right to a fair hearing as required by
this section by the most expedient means available to the recipient, including
by telephone.
(3) The recipient may
request a fair hearing by the most expedient means available to the recipient,
including by telephone.
