C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.24

Current through 2024-51, December 18, 2024

Subsection 144-101-I-1.24 - MEMBER APPEALS

1.24-1Right to Administrative Hearing

In accordance with 42 C.F.R. § 431.220 the Department must grant an opportunity for a hearing to:

A. Any member who requests it because his or her claim for services is denied or not acted upon with reasonable promptness; and B. Any member who requests it because he or she believes the agency has erroneously terminated, reduced, or suspended MaineCare medical eligibility or covered services.

1.24-2Notice of Intent to Deny, Terminate, Reduce or Suspend MaineCare Eligibility or Covered Services

A. Notice must be mailed or delivered in person to the member when there has been a denial, termination, suspension or reduction of eligibility for MaineCare orcovered services or when there has been a determination by a skilled nursing facility or nursing facility to transfer or discharge residents, as set forth below.

Specific information that must be in this notice includes:

1. A statement of the intended action;

2. An explanation of the reasons for the action, as well as a specific citation to the underlying state or federal regulations that support the action;

3. A statement that the member has a right to a hearing;

4. An explanation of exactly how to obtain a hearing;

5. A statement that a member may be represented by legal counsel, relatives, friends or a spokesperson and a list of selected legal service providers available to assist the member in arranging for legal counsel;

6. The name and telephone number of the person who should be contacted, should the member have questions regarding the notice; and

7. An explanation of the circumstances under which medical eligibility for MaineCare or covered services are continued if a hearing is requested.

B. Advance notice must be mailed or delivered in person to a member at least ten (10) calendar days before an action to deny, terminate, suspend, or reduce services becomes effective, except as required by licensing of other state mandates. A member is presumed to have been provided a notice if there is evidence of when the notice was placed in the mail system or delivered in person.

The advance notice requirement applies unless:

1. The Department has facts indicating that the action should be taken because of probable fraud, and the facts have been verified if possible, in which case advance notice of five (5) calendar days is required;

2. The Department has factual information confirming the death of a member;

3. The agency receives a clear written statement, signed by the member, that the member no longer wishes services; or gives information that requires termination or reduction of services and indicates that the member understands that this termination or reduction is the result of giving that information;

4. The member has been admitted to an institution where he or she is ineligible for further services;

5. The member's whereabouts are unknown, and the post office returns agency mail directed to him or her indicating no forwarding address;

6. The member has been accepted for services by another local jurisdiction, state or territory; or

7. A change in the level of medical care is prescribed by the member's physician or primary care provider where authorized.

C. Continuation of MaineCare eligibility or services during the appeal process applies as follows:

1. In accordance with 42 C.F.R. § 431.230 and when this section requires advance notice, MaineCare Services currently being provided will not be terminated, reduced, or suspended until an administrative hearing decision is rendered provided that the member requests an administrative hearing before the date of action. This applies unless it is determined at the hearing that the sole issue is one of federal or state law or policy, and the Department promptly informs the member in writing that services are to be terminated, reduced or suspended while awaiting the hearing decision.

2. The date of action means the intended date on which a termination, reduction or suspension becomes effective.

3. For Order of Reference decisions, as defined in the Administrative Hearings Regulations, the Department will take action to terminate, reduce or suspend services five (5) business days from the date of the final agency decision.

1.24-3Procedure to Request an Administrative Hearing

A member may request an administrative hearing if he or she is aggrieved by any Departmental action that may deny, terminate, reduce, or suspend services provided by MaineCare. The Department may respond to a series of individual requests for a hearing by conducting a single group hearing. Members must follow the procedures

described in this section when requesting an administrative hearing.

A. A member or his/her authorized representative may request an administrative hearing.

B. Unless otherwise specified in this Chapter, a request for an administrative hearing must be received within sixty (60) calendar days of the date of written notification to the member of the action the member wishes to appeal.

C. Unless otherwise specified in this Manual, the request must be made by the member or his or her representative, in writing or verbally, to: MaineCare Member Services, P. O. Box 709, Augusta, ME 04332, or an address otherwise specified by the Department in a written notice, for a hearing with the DAH, Department of Health and Human Services. For the purposes of determining when a hearing was requested, the date of the hearing request shall be the date on which the request for a hearing is received by MaineCare Member Services. The date a verbal request for an administrative hearing is made is considered the date of request for the hearing. MaineCare Member Services may also request that a verbal request for an administrative hearing be followed up in writing, but may not delay or deny a request on the basis that a written follow-up has not been received. MaineCare Member Services shall send a fax or copy of all hearing requests to a Hearings Representative and to the DAH no later than five (5) business days after receiving the request. MaineCare Member Services shall send all expedited hearing requests within twenty-four (24) hours of identifying the request.

D. The hearing will be held in conformity with the Maine Administrative Procedure Act, 5 M.R.S. §8001et seq. and the Department's Administrative Hearings Regulations.

E. The hearing will be conducted at a time, date and place convenient to the parties and at the discretion of the DAH, and a preliminary notice will be given at least ten (10) calendar days, from the mailing date. Shorter notice may be given in order to comply with provisions of Section 1.14-1 governing denials of mental health services. In scheduling a hearing, there may be instances where the hearing officer shall schedule the hearing at a location near the member or by telephone or interactive television system.

F. The Department and the member may be represented by others, including legal counsel and may have witnesses appear on his or her behalf.

G. An impartial official will conduct the hearing.

H. The hearing officer on his or her own motion or at the request of either Department representatives or the member may request or subpoena persons to appear where that person can be expected to present testimony or documents relating to the issues at the hearing. The cost of the subpoena shall be borne by the Department.

I. When a medical assessment as defined in 42 C.F.R. § 431.240(3)(b) by a medical authority other than the one involved in the decision under question is requested by the hearing officer or the member, and considered necessary by the hearing officer, it will be obtained at the Department's expense, and forwarded to the member or the member's representative and hearing officer allowing both parties to comment.

J. When the member, the Department, or an Authorized Entity of the Department requests a delay, the hearing officer may reschedule the hearing, after notice to both parties.

K. The decisions, rendered by the hearing authority, in the name of the Maine Department of Health and Human Services will be binding upon the Department, unless the Commissioner directs the hearing officer to make a proposed decision reserving final decision-making authorization to him or herself.

L. Any person who is dissatisfied with the hearing authority's decision has the right to judicial review under Maine Rules of Civil Procedure, Rule 80 C.

1.24-4Procedure to Request an Expedited Appeal

Members may request an expedited appeal. Requests for an expedited appeal must be submitted in writing to the MaineCare Hearings Representative and contain all documents supporting the request. The Hearings Representative shall forward the request and all supporting documents to the DAH upon receipt.

A. The DAH may grant a member's request for an expedited appeal if it determines that the member has proven that the time otherwise permitted for a hearing could jeopardize the individual's life, health, or ability to attain, maintain, or regain maximum function. In making this determination, the DAH may consider the following factors:

1. Any submitted medical evidence of record;

2. Medical opinions from the member's health care providers or Department;

3. The timing of the member's request;

4. The current level of services authorized for the member;

5. Refusal or failure of the member or their representative to appear for a status conference; and

6. Any other factors the DAH determines relevant.

The DAH may require the parties or their representatives to participate in a status conference prior to ruling on a request for an expedited appeal.

B. The DAH will notify the member and Department representative whether the request is granted or denied as expeditiously as possible.

If a member is granted an expedited hearing, the Department must take final agency action on the appeal:

1. For a claim related to eligibility, nursing facilities, or preadmission and annual resident review, as expeditiously as possible and no later than seven (7) working days after the agency receives the expedited appeal request; or

2. For a claim related to services or benefits, as expeditiously as possible and no later than three (3) working days after the Department receives the expedited appeal request.

C. The Department is not required to take final agency action within the timelines above if:

1. The Department cannot reach a decision because the member requests a delay or fails to take a required action; or

2. There is an administrative or other emergency beyond the Department's control.

The Department must document the reasons for any delay in the member's record.

D. The DAH may make any adjustments to the hearing process as it deems necessary to accommodate the expedited time frame for the hearing. These adjustments may include, but are not limited to:

1. Limiting the time for the hearing;

2. Limiting the number of witnesses each party may call;

3. Limiting the timeframe to submit evidence;

4. Limiting the ability of parties to submit written closing statements or other post-hearing briefs;

5. Requiring parties to participate telephonically or by other remote means; and

6. Any other modification the DAH deems necessary.

If a member objects to any adjustment made by the DAH, the member may withdraw their request for an expedited appeal and have their appeal proceed under normal procedures. If the member does not withdraw their request, the member waives any objections to the adjustments.

1.24-5Dismissal of Administrative Hearing Requests

A. If any of the following circumstances exist, the DAH may dismiss the request for an administrative hearing. This dismissal is the final agency action on the matter.

1. The member withdraws the request for a hearing.

2. The member, without good cause, abandons the hearing by failing to appear.

3. The sole issue being appealed is one of federal or state law requiring an automatic change adversely affecting some or all members. The procedure to follow when requesting a change in state policy is described in Section 1.06-4(D) of this Manual.

B. Where an applicant's or member's request for an administrative hearing is dismissed pursuant to this section, the DAH shall notify the member of his/her right to appeal that decision in Superior Court.

1.24-6Corrective Action

The Department must promptly make corrective payments when appropriate, retroactive to the date an incorrect action was taken by the Department if:

A. The hearing decision is favorable to the applicant or member; or

B. The agency decides in the applicant or member's favor before the hearing.

C.M.R. 10, 144, ch. 101, ch. I, § 144-101-I-1, subsec. 144-101-I-1.24