D.C. Mun. Regs. tit. 29, r. 29-7307

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

Rule 29-7307 - NOTICE AND FAIR HEARING RIGHTS

7307.1

The Department shall provide timely notice of eligibility and enrollment determinations and the right to appeal to applicants and beneficiaries of the Immigrant Children's Program consistent with the requirements set forth in District law and rules.

7307.2

The Department shall provide timely and adequate notice to applicants and beneficiaries of the Immigrant Children's Program in cases of intended adverse action such as an action to deny, discontinue, terminate, suspend, or change the manner or form of medical assistance.

7307.3

An adequate notice shall include:

(a) A statement of what action(s) are intended;

(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 medical assistance is provided during the pendency of a hearing.

7307.4

A timely notice of an adverse action shall be issued (including mail postmark or time stamp for electronic submissions) at least fifteen (15) calendar days before the date an action would become effective, except as permitted under §§ 7307.5 and 7307.6.

7307.5

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 medical assistance is no longer required; or

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

(c) A beneficiary's whereabouts are unknown and the 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 medical assistance in another state and that fact has been verified.

7307.6

Under the circumstances identified in § 7307.5, the Department shall issue notice no later than the effective date of action.

7307.7

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.

7307.8

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

(a) An application for medical assistance in the Immigrant Children's Program is denied;

(b) Eligibility for medical assistance under the Immigrant Children's Program is suspended;

(c) Eligibility for medical assistance under the Immigrant Children's 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 medical assistance in error; or

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

7307.9

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.

7307.10

The Department may deny or dismiss a request for a fair hearing if:

(a) The applicant or beneficiary withdraws the request in writing; or

(b) The applicant or beneficiary fails to appear at a scheduled hearing without good cause.

7307.11

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

(a) Telephone;

(b) Mail;

(c) In person; or

(d) Through other commonly available electronic means.

7307.12

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

7307.13

Where the Department provides notice as required under §§ 7307.3 through 7307.6, 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 it is determined at the hearing that the sole issue is one of Federal or District law or policy.

7307.14

If action is taken without timely notice when timely notice is required by law, the Department shall reinstate medical services if a beneficiary requests a hearing not more than ten (10) calendar days after the postmark of the written notice of the action.

7307.15

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

7307.16

The Department shall reinstate and continue services until a decision is rendered after a hearing if:

(a) Action is taken without the advance notice required under §§ 7307.5 through 7307.6;

(b) The beneficiary requests a hearing within ten (10) calendar days from the date that the beneficiary receives the notice of action. The date on which the notice is received is considered to be five (5) calendar days after the date on the notice, unless the beneficiary shows that notice was not received within the five (5) calendar day period; and

(c) The Department determines that the action resulted from other than the application of federal or District law or policy.

7307.17

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.

7307.18

Fair hearings and appeals for the District's Immigrant Children's Program shall be administered through the Office of Administrative Hearings (OAH) in accordance with D.C. Official Code § 4-210.01et seq. and amendments thereto, and 1 DCMR § 2970 through 1 DCMR § 2978, and amendments thereto.

D.C. Mun. Regs. tit. 29, r. 29-7307

Final Rulemaking published at 70 DCR 001669 (2/3/2023)