All Medicaid Programs |
Obsolete Policy |
The DWS Office of Adjudications and Appeals must issue a written decision to all parties involved in the hearing. The Office of Formal Hearings at the Department of Health will issue the written decision if the hearing was the result of a decision by the State Medicaid Disability Office (SMDO). (Sec. 125-1)
Send copies of the decision to the Department of Workforce Services Fair Hearing Team. This group is responsible to forward the decision to the client, the client’s authorized representative and selected representatives of the Department of Workforce Services(DWS) and the Department of Health(DOH).
What Must Be Included in the Decision
A description of the evidence that was presented.
Findings of facts based on the evidence. The decision must be based on more than just hearsay evidence.
Conclusions of laws and rules upon which the decision was based.
Statement of the reason for the decision.
Statement of action the agency must take, if any.
Right to request a Superior Agency Review from the Department of Health and how to make the request.
Superior Agency Review
The Department of Health, as the Single-State Medicaid Agency, is a party to all fair hearings concerning eligibility for medical assistance programs. DOH conducts appeals and has the right to conduct a Superior Agency Review of medical assistance hearing decisions rendered by the Office of Adjudications and Appeals or the Office of Formal Hearings.
The applicant or recipient may appeal the hearing decision to DWS or the Department of Health. The request for agency review must be made in writing within 30 days of the mailing date of the hearing decision.
The DWS or DOH hearing decision becomes final 30 days after the decision is sent unless the Department of Health will conduct a Superior Agency Review. The Department of Health will conduct a Superior Agency Review when the applicant or client appeals the hearing decision or if the Department of Health disagrees with the decision.
The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.
The Department of Health notifies the hearing offices whenever it will conduct a Superior Agency Review. The hearing decision is suspended until the Department of Health issues a final Decision and Order on Agency Review.
A Decision and Order on Agency Review from the Department of Health becomes final upon issuance.
Within 30 days of the date the Decision and Order on Agency Review is issued, the applicant or client may file a petition for judicial review with the District Court. Failure to appeal a hearing decision to the Department of Health negates this right to a judicial appeal.
Clients are not entitled to continued benefits pending judicial review by the District Court.
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.