D.C. Mun. Regs. tit. 22, r. 22-B3308

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 22-B3308 - NOTICE AND FAIR HEARING RIGHTS

3308.1

The Department shall provide timely notice of eligibility and enrollment determinations and the right to appeal to Alliance program applicants and beneficiaries consistent with the requirements set forth in District law and rules.

3308.2

The Department shall provide timely and adequate notice to Alliance program applicants and beneficiaries in cases of intended adverse action such as an action to deny, discontinue, terminate, or change the manner or form of Alliance program services.

3308.3

An adequate notice shall include:

(a) A statement of the intended action(s);

(b) The reason(s) for the intended action(s);

(c) Specific law and regulations supporting the action, or the change in federal or District law that requires the action(s);

(d) An explanation of an applicant or beneficiary's right to request an administrative or fair hearing; and

(e) The circumstances under which Alliance program benefits are provided during the pendency of a hearing.

3308.4

A timely notice of an adverse action shall be issued (based on the postmark for physical mail or time stamp for electronic submissions) at least fifteen (15) calendar days before the date an adverse action would become effective, except as permitted under §§ 3308.5 and 3308.7.

3308.5

The Department may dispense with timely notice, but shall send adequate notice under the following circumstances:

(a) The Department has factual information confirming the death of a beneficiary;

(b) The Department receives a documented and signed statement from a beneficiary:

(1) Stating that Alliance program benefits is no longer required; or

(2) Providing information which requires termination or reduction of Alliance program benefits and indicating that a beneficiary understands the consequence of supplying the information;

(c) A beneficiary's whereabouts are unknown and Department mailings, directed to the beneficiary, have been returned by the post office indicating no known forwarding address; or

(d) A beneficiary has been deemed eligible for health care or medical services in another state and that fact has been verified.

3308.6

Under the circumstances identified in § 3308.5, the Department shall issue notice no later than the effective date of the adverse action.

3308.7

The Department may issue a notice no later than five (5) calendar days before the date of action if the Department has facts related to probable fraud by the beneficiary; and those facts have been verified, if possible, through secondary sources.

3308.8

The Department shall automatically schedule an administrative review of an adverse action from the Department prior to the fair hearing. The scheduling of an administrative review shall not affect the individual's right to request a fair hearing.

3308.9

The Department shall grant an opportunity for a fair hearing when:

(a) An application for the Alliance program is denied;

(b) Eligibility for the Alliance program is suspended;

(c) Eligibility for the Alliance program is terminated;

(d) An applicant or beneficiary believes the Department has taken an action which affects the receipt, termination, amount, kind, or conditions of the Alliance program in error;

(e) A beneficiary was denied coverage of, or payment for, medical services;

(f) A beneficiary who is dissatisfied with the District's determination that disenrollment from an MCO is appropriate; or

(g) A claim was denied or not acted upon with reasonable promptness pursuant to D.C. Official Code § 4-210.02(a).

3308.10

The Department shall not grant a hearing if the sole issue is a federal or District law requiring an automatic change that adversely affects some or all beneficiaries.

3308.11

The Office of Administrative Hearings (OAH) may grant a hearing, or deny or dismiss a request for a fair hearing in accordance with its rules under Chapter 28 of Title 1 of the DCMR..

3308.12

An individual, an adult who is in the individual's household, or an authorized representative shall submit a fair hearing request via:

(a) Telephone;

(b) Fax;

(c) Mail;

(d) In person; or

(e) Through other commonly available electronic means (including online via a web-based portal.

3308.13

An applicant or beneficiary seeking a fair hearing shall submit a fair hearing request no later than ninety (90) days following the date of the notice of adverse action.

3308.14

Where the Department provides notice as required under §§ 3308.3 through 3308.7, and the beneficiary requests a fair hearing before the date of adverse action, the Department may not terminate or reduce services until a hearing decision is rendered unless:

(a) It is determined at the hearing that the sole issue is one of Federal or District law or policy; and

(b) The Department promptly informs the beneficiary in writing that medical services will be terminated or reduced pending the hearing decision.

3308.15

The Department may reinstate services under the Alliance program if a beneficiary requests a hearing no more than ten (10) days after the date of action.

3308.16

Reinstated services shall continue until a hearing decision is reached unless, the hearing has determined that the sole issue is one of federal or District law or policy.

3308.17

The Department shall reinstate and continue services until a hearing decision is rendered if action was taken without timely notice, when timely notice is required by law, and the recipient requests a hearing within ten (10) days of the postmark of the written notice of the action.

3308.18

If a beneficiary's whereabouts are determined to be unknown, discontinued services shall be reinstated if the beneficiary's whereabouts become known during the time the beneficiary is eligible for services.

3308.19

Fair hearings and appeals for the Alliance program shall be administered through the OAH in accordance with §§ 2970 through 2978 of Title 1 of the DCMR, and D.C. Official Code § 4-210.01et seq..

D.C. Mun. Regs. tit. 22, r. 22-B3308

Final Rulemaking published at 69 DCR 4550 (5/6/2022)