10- 144 C.M.R. ch. 286, § V

Current through 2024-51, December 18, 2024

Section 144-286-V - APPEALS

A. APPLICANT, PARTICIPANT OR VENDOR APPEALS

1. Any applicant, participant or vendor adversely affected by a local or State Agency decision has the right to a formal hearing in only the following instances:

a. Participant

i. Denial of participation at certification or recertification;

ii. Disqualification from the Program during the certification period; and

iii. Placement on a waiting list.

b. Vendor

i. Denial of authorization;

ii. Disqualification from the Program during the contract period; and

iii. Denial of vendor claims.

2. Administrative hearings will be conducted in accordance with the rules contained in the WIC Federal Regulations 7 CFR § 246.18 and Department of Health and Human Services Administrative Hearing Regulations, 10-144 CMR Chapter 1.

3. Any participant or vendor adversely affected by a local or State Agency decision shall be informed in writing at least fifteen (15) days prior to the effective date of the action, of the reasons for the action and of the right to an administrative hearing.

4. Any applicant found ineligible for the Program or placed on the waiting list shall be immediately informed in writing of the action, of the reasons for the action and of the right to an administrative hearing.

5. A request for an administrative hearing is defined as a written or verbal statement by an applicant, participant or vendor requesting the opportunity to present his/her case to a higher authority.

6. Requests for an administrative hearing must be made within sixty days from the date of the written notice of the adverse action.

7. Requests received by local agencies shall be forwarded to the State Agency within three working days of receipt.

8. The Department shall not deny or dismiss a request for an administrative hearing unless:

a. The request is not received within the time limits set by the Department;

b. The request is withdrawn in writing by the appellant or representative;

c. The appellant or representative fails, without good cause, to appear at the scheduled hearing; or

d. The appellant is not entitled to a hearing as set forth above.

9. Applicants or participants who are denied benefits at initial certification or at subsequent certifications may appeal the denial but shall not receive benefits while awaiting the hearing.

10. Participants who request an administrative hearing as a result of the termination of benefits during a certification period and within the fifteen days advance adverse notice period shall continue to receive Program benefits until a decision is reached or the certification period expires, whichever comes first.

11. Adverse actions against a vendor shall be postponed until an administrative hearing decision is reached, unless otherwise required by law.

12. Administrative hearing dates will be scheduled to take into consideration the convenience of the appellant, both in terms of time and location.

13. The appellant is solely responsible for the cost of his or her legal counsel.

14. The State Agency shall immediately forward any request for withdrawal of an administrative hearing to the Hearing Officer.

15. An administrative hearing may not be delayed or canceled for the purpose of considering a possible adjustment unless the appellant requests such a delay or cancellation.

16. The appellant shall be provided with adequate opportunity to examine all records and documents to be presented at the administrative hearing, at any time after a request for a hearing has been made.

17. Any representative of the appellant must have written authorization from the appellant to examine such records.

18. All administrative hearings will be conducted in accordance with the rules contained in the Department of Health and Human Services Administrative Hearings Regulations 10-144 CMR Chapter 1.

19. All administrative hearing decisions will be issued in accordance with the rules contained in the Department of Health and Human Services Administrative Hearings Regulations 10-144 CMR Chapter 1.

20. If the administrative hearing decision is in favor of the appellant, and benefits were denied or discontinued, benefits shall begin once a decision is made.

21. If the decision is not in favor of the appellant, continued benefits or participation shall be terminated as soon as administratively feasible as decided by the Hearing Officer. An appellant may appeal an unfavorable decision to Superior Court pursuant to M.R.Civ.P.80C. However, unless otherwise ordered by the Superior Court, the Hearing Officer's decision shall not be stayed, and benefits or participation shall continue to cease.

B. LOCAL AGENCY APPEALS

1. Any local agency adversely affected by a State Agency decision has the right to appeal certain Department decisions.

2. The expiration of a local agency's agreement is not subject to administrative appeal.

3. When the decision relates to an agreement dispute, the following standards shall apply:

a. The local agency must submit a written or oral request for a review to the State Agency. Said request must be received by the State Agency within thirty calendar days from the date of the State Agency's decision letter;

b. The review shall be conducted by the Director, Maine Center for Disease Control and Prevention or a designee;

c. The Director shall notify the local agency of the decision, in writing, within five calendar days of the review. The decision shall include findings of fact regarding the agreement dispute; and

d. The decision of the Director shall represent the final decision of the Department and may be appealed to Superior Court pursuant to M.R.Civ.P.80C.

4. When the decision relates to the non-renewal of an agreement or the denial of an initial application, the following standards shall apply:

a. When the Department has determined that it will not approve an initial application or negotiate a renewal of a local agency's agreement, the Department shall notify the local agency of the decision in writing and of the agency's right to a review by the Department.

b. If a written or verbal request for such is postmarked within thirty days of the date of the State Agency's notification letter, the Director, Maine Center for Disease Control and Prevention, will conduct an informal conference within ten days of the request. The Director will issue a written decision within five calendar days of the conference.

c. If the local agency is dissatisfied with the Director's decision, the local agency may request a formal hearing with the Department's Administrative Hearing Unit. The local agency must request the formal hearing within ten calendar days of the informal review decision by making a written or oral request to the Commissioner, Department of Health and Human Services, or the WIC State Agency. A formal hearing will be conducted pursuant to 10-144 CMR Chapter 1.

5. When the decision relates to the termination of an agreement, the following standards shall apply:

a. When the Department notifies a local agency, in writing, of its decision to terminate an agreement, the local agency may request a decision review within ten calendar days from the date of the State Agency's notification letter, by making a written or oral request to the Director, Maine Center for Disease Control and Prevention.

b. The Department shall provide at least sixty days notice of its decision to terminate the agreement.

c. If a timely request was made, the Maine Center for Disease Control and Prevention Director, or a designee will conduct an informal conference within ten calendar days of the request. The Director will issue a written decision within five calendar days of the conference.

d. If the local agency is dissatisfied with the Director's decision, the local agency may request a formal hearing with the Department's Administrative Hearings Unit within ten calendar days from the date of the Director's decision letter. The Department shall continue funding the agency until a hearing decision is reached. An administrative hearing will be conducted pursuant to the Department of Health and Human Services Administrative Hearing Regulations, 10-144 CMR Chapter 1.

6. When the decision relates to the appeal of an audit, the following standards shall apply:

a. A local agency dissatisfied with the results of a Department conducted fiscal audit shall have the right to an informal conference review by the Department if a written request for such is received within calendar days of the date of the final audit report.

b. The Maine Center for Disease Control and Prevention shall, within thirty calendar days of receipt, acknowledge, in writing, a request for an informal review providing the appellant with the date, time and place of the review.

c. In the event the Maine Center for Disease Control and Prevention requests additional agency information, the local agency shall submit such information to the Maine Center for Disease Control and Prevention within thirty calendar days in order to be considered. No final decision shall be rendered until the information is received, or the time period for submission has elapsed.

d. The Maine Center for Disease Control and Prevention shall notify the appellant, in writing, within thirty calendar days of the informal conference or the elapsed period for submission of additional information of the decision rendered by the State Agency.

e. If the appellant is dissatisfied with the Maine Center for Disease Control and Prevention's decision, the appellant shall have the right to request a formal hearing with the Department's Administrative Hearings Unit within calendar days of receipt by making a written request to the WIC State Agency.

f. If the final decision requires the local agency to return funds to the Department, the local agency shall return such funds within thirty calendar days of the date of the decision letter unless an alternate payment has been approved by the State Agency.

g. If the funds are not returned within thirty calendar days or an alternate payment has not been approved, the Director, Maine Center for Disease Control and Prevention shall have the right to reduce the local agency's current allocation of Maine Center for Disease Control and Prevention funds.

10- 144 C.M.R. ch. 286, § V