Medicaid Policy
Medicaid Policy
1. The Department of Workforce Services, as the eligibility agency, handles all medical assistance hearings except hearings for foster care, subsidized adoption or disability claims determined by the State Medicaid Disability Office (SMDO).
2. The Office of Formal Hearings at the Department of Health and Human Services (DHHS) conducts all hearings concerning Medicaid eligibility for foster care, subsidized adoption and disability claims determined by the SMDO.
3. An expedited hearing is processed in 7 days and can only be granted if the individual can verify that the standard time for a hearing (90 days) could jeopardize their life, or ability to reach, maintain, or return their health to maximum function (125-4).
4. The Hearings Office must notify the individual and the local office of the time, date, place, and reason for the hearing. The agency must mail the notice at least seven days before the hearing. However, if all parties agree, the hearings officer may hold the hearing sooner. The Hearing Officer may choose to schedule pre-hearing meetings as a way to clarify the issue, arrange for the exchange of documents and identify witnesses.
5. The Hearings Office generally schedules hearings as phone hearings. The individual can ask for an in-person hearing by contacting the Administrative Law Judge before the date of the scheduled hearing.
6. For hearings held in person, all parties meet at the same place for the hearing.
7. For a hearing held by telephone, the Hearing Officer remains in the office and conducts the hearing via telephone conference call to other locations where the parties involved in the hearing are located.
8. The ALJ, eligibility agency or individual can request a postponement of the hearing. The postponement cannot exceed a total of 30 days.
a. The request for the postponement must be made before the scheduled hearing.
b. The request must be made orally or in writing to the ALJ assigned to hear the case.
c. The party requesting the postponement must show a reasonable reason for the request.
d. The agency must hold the rescheduled hearing within 30 days of the original hearing date.
9. The individual may have a representative, including legal counsel.
10. The eligibility agency may have legal counsel.
11. No party to the hearing can discuss the issues pertinent to the hearing with the Hearing Officer without all interested parties either being present or subsequently informed of the content of the discussion.
12. Fair Hearings are not open to the public. Only the following individuals may attend:
o The Hearing Officer.
o Representatives, legal counsel and witnesses from the Department of Health and Human Services and Department of Workforce Services.
o A transcriber, as determined by the Hearing Officer.
o The applicant or individual, friends or relatives of the individual’s choice, and a designated representative for the individual as space permits.
13. Cancelling a Hearing.
a. The applicant or individual must notify the DWS Office of Adjudication and Appeals or the DHHS Office of Formal Hearings if they want to cancel the hearing and not proceed with the appeal.
b. The ALJ issues a decision dismissing the appeal.
c. This decision has the effect of upholding the eligibility agency’s original action.
d. The customer has 30 days to reinstate the appeal by filing a written request for reinstatement to the Division of Adjudication.
14. Failure to Appear for a Fair Hearing.
o If either party fails to appear at the hearing in person, by telephone or through a representative, the ALJ issues a decision based on the available evidence.
15. Reopening a Fair Hearing.
a. If either party fails to participate in the hearing, but the agency has not issued a decision, the party may request the hearing be reopened.
b. If the agency has issued a decision, either party that failed to participate personally may request the decision be set aside and a new hearing scheduled.
i. The request must be in writing and mailed, faxed or delivered to the Division of Adjudication within 10 days of the issuance of the decision.
ii. Individuals who request the hearing be reopened more than 10 days after the issuance of the decision must show good cause for not making the request within the allotted time limit.
iii. A request made by the eligibility agency more than 10 days after the decision will not be granted.
16. Good Cause to Reopen a Fair Hearing.
a. Failure to report as instructed at the time and place of the scheduled hearing is the equivalent of failing to participate, even if the party reports at another time or place.
b. Good cause for failing to participate in a hearing does not include such things as:
o Failure to read and follow instructions on the notice of the hearing.
o Failure to arrange for personal circumstances such as transportation or child care.
o Failure to arrange for receipt or distribution of mail.
o Failure to delegate responsibility for participation in the hearing,
o Forgetfulness.