DHHS - Medicaid Policy Manual
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  Medicaid Policy                                                                 

 

125-3 Benefits Pending A Hearing Decision

Effective Date: April 1, 2014

Previous Policy

 

  1. When a recipient asks for a fair hearing, the recipient may be eligible to receive medical benefits while the hearing is pending.  Applicants cannot receive medical benefits during the hearing process.  Continue benefits for a recipient in the following two instances.
    1. Continue the medical assistance if the member asks for a hearing any time before the effective date of the action or by the close of business on the 10th day from the date the Notice of Decision was received by the member. (The notice is considered to be received 5 days from the date on the notice.)   (See Sec. 811 for advance notice requirements.)
      1. If the 10th day after the notice was mailed is a non-business day, then continue the medical assistance if the member makes the request no later than the first business day  following the 10th day.
      2. At the hearing or pre-hearing conference, the Hearing Officer will determine what the actual issues are.  If the Hearing Officer finds the only reason for the hearing is because of Federal or State policy or law and discontinues the fair hearing process, stop the medical assistance.  Otherwise, continue the medical assistance until you get the hearing decision.
    2. When Social Security determines an individual is not disabled or blind, or finds the individual no longer meets disability or blindness criteria, continue medical assistance ONLY IF the member was receiving Disabled or Blind Medicaid before the agency receives the SSA denial, and the member files the SSA appeal timely and notifies the Medicaid worker of the appeal.  
      1. The computer match record for SSI benefits may show the member has filed an appeal and that is effective verification, too.
      2. If the member was applying for disability benefits other than SSI, ask for verification from the Social Security agency of the appeal status.  If the member has an attorney helping with the SSA appeal, the lawyer can verify the appeal status.
      3. Benefits may continue throughout the administrative appeal process with SSA.  If SSA's final decision upholds the decision that the person is not blind or disabled, stop the continued Medicaid benefits giving proper notice.  The member must repay the continued Medicaid benefits. (825-2.1 # 3).
      4. If Disabled or Blind Medicaid was not approved before we receive an SSA denial, the applicant cannot receive benefits pending the SSA appeal.  (See 125-3, #1)
  2. Member's Requirement to Repay Continued Benefits (825-2.1 # 3)
    1. The recipient must repay benefits if the hearing decision goes against the recipient.  The agency must tell the member of the requirement to repay benefits pending the hearing decision.  
    2. Repayment is required even if the recipient does not use any medical or mental health services while the hearing is pending. This is also the case if a recipient receives continued benefits pending an appeal to Social Security about a disability decision, and the appeal goes against the member.  This information is part of the hearing request form. (825-2.1 # 3)
    3. Repayment of benefits includes all expenses paid by the Medicaid agency on behalf of the recipient including:  premiums and fees for a Medicaid Health Plan, the contracted mental health provider serving Medicaid recipients in a given area, Medicare or other health insurance, medical transportation and all fee-for-service expenses.
  3. How to Handle Case Changes Before the Hearing Decision
    • When a new change happens during the continued benefits time, adjust the medical assistance, holding constant whatever item is the subject of the hearing.  Notify the recipient of the effect of the change.  If the new change causes the individual to be ineligible for medical assistance, stop the continued benefits giving proper notice.  The individual has the right to ask for a new hearing on the new change and may receive continued benefits if the criteria under 125-3 are met.
  4. Appeals
    1. Recipients who were receiving benefits pending the hearing decision are not entitled to continued benefits during an appeal to District Court.  
    2. Recipients are not entitled to continued benefits during a court appeal of a Social Security denial, i.e.:  they have exhausted SSA's administrative appeal process.
    3. When the hearing decision upholds the agency's decision or the SSA appeal decision upholds SSA's original denial, stop assistance at that time.
  5. When to Stop Assistance Pending the Hearing Decision
    1. A recipient who meets the criteria to receive benefits pending the hearing decision may choose not to receive continued benefits.  
      1. Do not provide benefits pending the hearing decision if the recipient says he or she does not want benefits while the hearing process or SSA appeal goes on.  
      2. The recipient can mark the box on the hearing request form or make the request by telephone or in person to say he does not want continued benefits.
      3. Note the request and the date on the case narrative, discontinue assistance and send a notice confirming the recipient’s decision.
      4. If a recipient who initially declined the continued benefits later says he wants to receive benefits while the hearing is still in process, confirm that the hearing is still pending.  Reopen the case from that point forward.  Document the request.   Do not open prior months.   Once a hearing decision has been made, follow that decision.
    2. If the Hearing Officer states, in writing, that the only reason for the hearing is because of Federal or State policy or law and decides not to hold a hearing, stop the medical assistance at that time.  (The Hearing Officer decides what the issues are at the hearing or pre-hearing conference.)  Otherwise, provide the medical assistance until a hearing decision is received.
    3. If the recipient's whereabouts are unknown, stop the continued benefits and send notice to the last known address.  Reopen the case without requiring a new application if the recipient contacts the office within 30 days after the closure, still wants to receive benefits pending the hearing decision, and the hearing decision is still pending.  If the recipient contacts the office more than 30 days after the case is closed, reopen the case only from that point forward if the hearing is still pending.
    4. If another change makes the recipient ineligible, stop the continued benefits.  Send appropriate notice of the closure.  (See 125-3 #3 above)
    5. Do not provide continued benefits during an appeal to District Court.  (See sec. 125-6)