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MEDICAID DUE PROCESS RIGHTS

MEDICAID DUE PROCESS RIGHTS. What is the focus of this training?. The training covers the fair hearing process for Medicaid Home and Community Based Services (HCBS). What are the services under HCBS?. There are seven services under HCBS: Case management Homemaker Home health aide services

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MEDICAID DUE PROCESS RIGHTS

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  1. MEDICAID DUE PROCESS RIGHTS Center for Independence of the Disabled, NY (c) 2011

  2. What is the focus of this training? The training covers the fair hearing process for Medicaid Home and Community Based Services (HCBS).

  3. What are the services under HCBS? • There are seven services under HCBS: • Case management • Homemaker • Home health aide services • Personal care services • Adult day health • Habilitation • Respite care

  4. What is a fair hearing? A process that gives you the right to argue any changes being made to your HCBS benefits. This is a right that should be sought immediately upon a change of benefits or services.

  5. What is the fair hearing process? A hearing before the agency; or A hearing where evidence may be presented at the local level, with a right to appeal to a State agency.

  6. Informing You of Your Rights to a Fair Hearing • At the time you apply for Medicaid, the agency must inform you in writing • Of your right to a hearing; • How to get a hearing; and • That you may be represented by an attorney or other person. • The agency must also issue and make public its hearing process.

  7. What is an action that triggers a right to a fair hearing? • An action may be triggered by a: • Termination; • Suspension; or • Reduction of Medicaid eligibility or services. Action is a term that will be used through out this presentation An action can be a change in benefits or termination of benefits

  8. What must be included on the notice to a consumer for an action to take place? • A statement of what action the State plans to take; • The reasons for taking the action; • The regulation that supports the action; • An explanation of your right to present evidence at the hearing; • An explanation when Medicaid HCBS services may be continued if a hearing is requested.

  9. What type of advance notice is required? • The State or local agency must mail a notice at least 10 days before the date of action • Except if there is a possibility of fraud by the consumer – then the advance notice must be 5 days before the date of action.

  10. When is advance notice not required? • The agency may mail the notice on the date of the action if: • There are facts that support your dependent’s death; • Your dependent has been admitted to an institution; • Your whereabouts are unknown and the post office returns the mail stating there is no forwarding address; • A change in level of care is prescribed by your dependent’s doctor; • It receives a written statement signed by you that: • You no longer want services • You give information that leads to termination or reduction of services and understand that the information will lead to this consequence

  11. What is meant by continuing benefits? If an agency mails a timely notice and you request a hearing before the date of the action, the agency can only terminate or reduce your benefits if: • The agency informs you promptly and in writing that services will be terminated or reduced pending the hearing; • If you request a hearing not more than 10 days after the date of the action.

  12. What is meant by continuing benefits? • Benefits must continue until a decision is made. • If you lose at the hearing, the agency may seek payment for any services rendered.

  13. When is a fair hearing required? The State agency must grant a hearing to: • Anyone who requests it because his/her claim for services is denied or not responded to on a timely basis. • Anyone who requests it because he/she believes that the agency has made an error in the action taken.

  14. How do you request a fair hearing? • In writing or by phone; • Without the agency trying to limit or interfere with your request for a fair hearing; • With help from an agency to submit and process your request for a fair hearing, if you wish; • Within a reasonable time usually set by the agency (not greater than 90 days from mailing of notice).

  15. When can a fair hearing be denied or dismissed? • If you withdraw your request in writing. • You fail to appear at a scheduled hearing without a good reason or cause.

  16. When can benefits be reinstated? Other reasons for reinstatement • Action is taken without notice in advance; • You request a hearing within 10 days of the mailing of the notice; and If your whereabouts are unknown, services that were stopped must be reinstated upon knowledge of whereabouts and eligibility for services.

  17. What is the agency’s role if you lose the fair hearing? The agency must: • Inform you of the decision on the hearing; • Inform you of your right to appeal to the State agency, in writing, within 15 days of the mailing of the decision; • Inform you of your right for a hearing that starts over from the beginning; • Stop benefits after you lose the hearing.

  18. What are the procedures in an appeal process? • If you do not ask for a new hearing, the State agency fair hearing may be based on the local agency’s record of its hearing. • A person, such as an Administrative Law Judge or hearing officer, who participated in the local agency decision that is being appealed cannot participate in the State agency hearing decision.

  19. How must a fair hearing appeal be conducted? • At a reasonable time, date, and place; • Only after adequate written notice of the hearing; and • By one or more individuals, like a hearing officer, who have not been directly involved in the initial determination of the action. • If the hearing involves medical issues and the hearing officer wants medical assessments other than the one in the initial hearing then they must be obtained at the agency’s expense and included in the file.

  20. What must the appeal cover? • The agency’s action or failure to act on a timely basis with regard to a claim for services, including both initial and following decisions regarding eligibility. • The agency decisions regarding changes in the type or amount of services.

  21. What are your procedural rights? • The right to examine at a reasonable time before and during the hearing: • The contents of the file • All documents and records to be used by the agency • To bring witnesses, an attorney or representative. • To establish all important facts and circumstances. • To present your argument without undue interference. • To question or refute any testimony or evidence, including a chance to confront and cross-examine adverse witnesses.

  22. How must the state agency who heard the appeal notify you of its decision? • The decision must be in writing; and • You must be notified of the right to seek judicial review, to the extent it is available.

  23. CORRECTIVE ACTION • The agency must promptly make corrective payments, retroactive to the date an incorrect action was taken if: • You win the hearing; or • The agency decides in your favor before the hearing.

  24. Requesting a State Fair Hearing Fair Hearing Section New York State Office of Temporary & Disability Assistance P.O. Box 1930 Albany, NY 12201 Or Call: 1-800-342-3334

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