Medicaid Policy
Medicaid Policy
1. The Department of Workforce Services (DWS) Division of Adjudications must issue a written decision to all parties involved in the hearing. The Office of Formal Hearings at the Department of Health and Human Services (DHHS) will issue the written decision if the hearing was the result of a decision by the State Medicaid Disability Office (SMDO). (Sec. 125-1)
2. Send copies of the decision to the DWS Fair Hearing Team. This group is responsible to forward the decision to the individual, the individual’s authorized representative and selected representatives of the DWS and possibly DHHS for review.
3. What Must Be Included in the Decision
a. A description of the evidence that was presented.
b. Findings of facts based on the evidence. The decision must be based on more than just hearsay evidence.
c. Conclusions of laws and rules upon which the decision was based.
d. Statement of the reason for the decision.
e. Statement of action the agency must take, if any.
f. Right to request an Agency Review from the DWS Division of Adjudications and how to make the request.
g. Citations of statutes, regulations, and eligibility criteria.
4. Agency Review
a. DHHS, as the Single-State Medicaid Agency, is a party to all fair hearings concerning eligibility for medical assistance programs. The DWS Division of Adjudications conducts appeals and DHHS has the right to conduct an Agency Review of medical assistance hearing decisions rendered by the DWS Division of Adjudications or the Office of Formal Hearings.
b. The applicant or recipient may appeal the hearing decision to DWS. The request for agency review must be made in writing within 30 days of the mailing date of the hearing decision.
c. The DWS hearing decision becomes final 30 days after the decision is sent unless DHHS will conduct an Agency Review. The DWS Division of Adjudications will conduct an Agency Review when the applicant or individual appeals the hearing decision, or if DHHS disagrees with a DWS decision, they will conduct an agency review.
d. The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.
e. DHHS notifies DWS Division of Adjudications it will conduct an Agency Review. The hearing decision is suspended until DWS Division of Adjudications issues a final Decision and Order on an Agency Review.
f. A Decision and Order on an Agency Review from DHHS is reviewed a second time by the DWS Division of Adjudications, and is either agreed upon and corrected, or rejected by the DWS Division of Adjudications who’s decision is then final.
g. Within 30 days of the date the Decision and Order on an Agency Review was issued, the applicant or individual may file a petition for judicial review with the District Court. Failure to appeal a hearing decision to DWS Division of Adjudications negates this right to a judicial appeal.
h. Individuals are not entitled to continued benefits pending judicial review by the District Court.
i. The eligibility agency must take case action within 10 calendar days of the date the decision becomes final if the decision reverses or modifies the eligibility agency's decision.