C.M.R. 10, 144, ch. 332, app 144-332-I
The purpose of a hearing is to review whether the Agency acted in accord with defined policy and procedural requirements in carrying out its actions. The review is usually requested in relation to proposed closings, denials, decreases in the level of coverage, and changes in deductible amounts. The hearing may also include questions of medical eligibility, classification for nursing care status and eligibility for retroactive coverage.
Hearings are not formal in the sense that there are oaths given, set formal procedures of addressing individuals concerned, or required procedures for entering objections or questioning at a particular time. Hearings are not casual conversations or arguments, however.
In addition to reviewing the decision itself, the Hearing Officer has the responsibility, at the hearing, to review whether appropriate procedures were followed in carrying out the action.
The Hearing Report
The agency representative has the responsibility to be prepared to give a report and to answer questions that may be asked by the Hearing Officer of other participants in the hearing. The Eligibility Specialist must make sure that proper written notice, with an advance notice period, if applicable, was forwarded to the applicant or recipient. The notice must cite the manual section on which the decision to deny or reduce benefits is based. It is not sufficient to state: "You have excess assets," or "You have excess income." The amount of assets or income should be given. In addition, the agency limit on assets or income should be cited. It might be necessary to cite more than one manual reference. If so, this should be done.
If the action results in a request for a hearing the Eligibility Specialist should submit a copy of the notice which was sent to the applicant or recipient to the Hearing Officer. The copy of the notice and other pertinent documents will become a permanent part of the Hearing Record.
When notified of a request for a hearing, the Eligibility Specialist must prepare a detailed report outlining what was done and why it was done. The report should indicate how the decision was made. If income is an issue, the Eligibility Specialist must elaborate on how net income was determined. If assets are an issue, the Eligibility Specialist must show what was considered as an asset. If medical eligibility is an issue, specifics should be given as to what went into the decision that the individual no longer is considered incapacitated or disabled in accord with agency policy. If the decision involved the Medical Review Team, contact must be made with that unit, The MRT will provide medical information if necessary.
If negative action is taken because information is incomplete, inconclusive or conflicting, the Eligibility Specialist must show what is inconclusive and why more information is needed. The Eligibility Specialist also has responsibility to show that specific information was requested and that the individual was given the opportunity to resolve questions before action was taken.
A copy of the report is sent to the individual requesting the hearing by the Division of Administrative Hearings prior to the hearing. If the agency is informed that the individual has a representative for the hearing, a copy of the report is also sent to the representative.
To the extent that the report is complete and concise, it will assist the Hearing Officer in conducting the hearing and will assist the applicant or recipient in understanding or questioning information.
The Hearing - The Hearing Officer will begin the hearing by giving an opening statement. In the opening statement, the Hearing Officer will:
I. cite the case name and basis purpose of the hearing;
II. request the names of all present;
III. remind all persons that the hearing is being recorded and that individuals should follow procedures by:
A. identifying themselves and referring to each other by name during the hearing;
B. make an effort to speak loud enough to be heard by all participants and face the recording equipment while talking.
Note that exhibits will be presented during the hearing.
After an opening statement by the Hearing Officer, the Eligibility Specialist will be asked to present a copy of the notice which was sent to the applicant or recipient.
The Hearing Officer will request a verbal report outlining the actions taken and the basis of the action. The report submitted by the Eligibility Specialist may be read or used as the basis for the verbal report. The Hearing Officer may ask additional questions if there areas which are unclear. In addition, copies of documents such as medical statements, budgets, lists of assets or medical bills may be requested by the Hearing Officer. When requested, copies of these items should be given to the Hearing Officer and the individual requesting the hearing.
The individual or the representative may question the decision of the Eligibility Specialist. Questions should be made through the Hearing Officer and not between the persons involved.
The individual requesting the hearing will be given the opportunity to:
I. question any information;
II. refute any information;
III. present any additional information or make any comments.
In situations where additional information is presented, the Hearing Officer will decide whether the information had a bearing on the decision in question at the time of the decision or whether the information relates to a period of time subsequent to the decision. If the latter is the situation, the information should only be considered in a re-application or in carrying out a subsequent review.
After both parties have presented information and entered any questions and the Hearing Officer is satisfied that pertinent data has been presented, the Officer will summarize the issue as much as possible.
A continuance of the hearing may be determined by the Hearing Officer if additional date is needed, obtainable, and not available at the hearing. If the applicant or recipient requests a continuance, the Hearing Officer will determine if it would be appropriate.
The agency representative should always have manual material at the hearing and be prepared to cite necessary data from the manual.
Appeal
When the above procedures are followed and there is further appeal through the courts, those persons responsible for representing the agency have issues that are clearly defined. In addition, procedures such as adequate and specific notice may be raised in court even if not mentioned at a hearing. Thus, it is necessary that procedures taken, as well as the decision made, be reviewed at the hearing.
C.M.R. 10, 144, ch. 332, app 144-332-I