DHHS - Medicaid Policy Manual
Click here to see this page in full context

  Medicaid Policy                                                                 

 

125-1 Fair Hearing Requests

Effective Date: March 1, 2019

Previous Policy

 

 

 

Applicant and recipients have the right to ask for a fair hearing in they disagree with the agency's decision about their eligibility for Medicaid benefits or if they disagree with a point in the eligibility process that affected their case.

 

A. Hearing Requests for Eligibility Decisions

 

  1. An applicant or recipient must request a hearing in writing or orally within 90 days of the date on the notice with which he disagrees.  
    1. The applicant or recipient may submit a written, verbal or email request for a fair hearing to the Department of Workforce Services or the Department of Health and Human Services.
      1. When the individual contacts either agency and requests a fair hearing, the worker will take the information, document the report and forward the request to the appropriate entity.
    2. The individual must make the request by the close of business on the 90th day, or if the 90th day is a non-business day, by the close of business on the first business day following the 90th day.
    3. If the agency denies a request to waive a penalty period due to undue hardship, the individual has 90 days from the date on the notice denying the undue hardship to request a fair hearing.
  2. Recipients receive continued medical benefits pending a hearing decision if they request a fair hearing before the effective date of the action or within 10 calendar days of the receipt of the notice, whichever is longer. The notice is considered to be received 5 days from the date on the notice, unless the recipient can show they did not receive the notice within the 5 day period (125-3).
  3. The individual must repay any benefits received pending the hearing decision if the hearing decision upholds the agency action (125-3).
  4. An individual has the right to refuse continued benefits pending a hearing decision.  
  5. The eligibility agency cannot hold hearings concerning the spousal resource assessment until the institutionalized person applies for Medicaid.  
  6. When a recipient requests a hearing to increase the spousal resource allocation for a community spouse of an institutionalized spouse, the "income first" rule applies to the hearing decision (573-2).
  7. An individual, an individual’s spouse, a parent of a minor child or an authorized representative may request a hearing.  

 B. Hearing Requests for Decisions by the State Medicaid Disability Office

  1. When the State Medicaid Disability Office (SMDO) decides a person is not disabled, the individual may request a fair hearing.
    • Hearings based on decisions of the SMDO are with the Office of Formal Hearings at the Department of Health and Human Services.   
    • The individual may also ask for a reconsideration of the disability decision as part of the fair hearing request.
    • Reconsideration is a good idea when the individual has new medical evidence that was not available for the original claim. 
    • If the SMDO re-affirms the original decision, the individual may continue with the fair hearing. 
  2. When the eligibility agency denies or stops medical assistance because of a denial of disability from Social Security (SSA), the Medicaid agency cannot conduct a hearing based solely on the SSA decision.  The individual can only appeal SSA’s denial of disability through the Social Security office.  See 125-3 for policy on continued benefits. The individual may request a hearing when there is new medical evidence not considered for the SSA decision (303-3).