Section 148-5-III - CONTRACT ADMINISTRATIONA. GENERAL ADMINISTRATIVE POLICIES1. PURPOSE: The Department of Health and Human Services is responsible for implementing and administering numerous broad-based federal and state programs. In this capacity, the Department must determine the parameters within which these programs will be operated and managed.
B. HEARINGS ON PURCHASED SERVICES1. PURPOSE: It is the policy of the Department of Health and Human Services that any person who is denied service or has services reduced or terminated by a provider organization under contract with the Department has the right to a state agency hearing. The Commissioner has delegated to the Administrative Hearings Unit the responsibility to conduct state agency hearings regarding purchased services. The state agency hearing shall be conducted in accordance with the current Administrative Procedure Act promulgated rules for state agency hearings.
2. STANDARDS OF CONDUCT a. Action on Requests for Service: i. Provider organizations shall give written notice within 30 calendar days of request for service to all persons who are denied services under a Office Child and Family Services contract or grant, using a Office prescribed form, or a form approved by the Office.ii. In all instances, notices of denial of service shall contain the client's state agency hearing rights.iii. The following actions shall not be subject to a provider agency conference or a state agency hearing on denial of service: a. The service(s) requested are not within the provider organization's contracted service or program description;b. Department contracted funds are depleted, or the total contracted amounts of service have been delivered;c. The provider organization is providing service at its maximum capacity;d. The request for service originates from a person who is not authorized or appointed to act on behalf of a client;e. The applicant does not meet the contracted eligibility criteria for the service(s) requested. iv. If a request for services is denied, the person denied may submit another request at any time that a change in circumstances occurs.v. Provider organizations shall retain copies of all notices of denial issued. b. Action to Terminate or Reduce Services: i. In cases of proposed action to discontinue, terminate, suspend, or reduce services, the provider organization shall give written notice to the client(s) at least 15 calendar days prior to the effective date of the action.ii. The written notice to discontinue, terminate, suspend or reduce services shall contain the following: a. The date of the intended action;b. The action the agency is proposing to take;c. The reason(s) for the proposed action;d. Reference to the specific rules or regulations supporting such action;e. Explanation of the individual's right to request a conference with the provider and/or a state agency hearing; andf. The time frame within which the conference and/or hearing request must be submitted in order for services to continue.iii. The following actions to discontinue, terminate, suspend or reduce services shall not be subject to a provider agency conference or state agency hearing: a. Reduction, change or termination of service(s) resulting from state program changes which have been implemented through a rulemaking procedure, in accordance with the Administrative Procedure Act;b. Reduction or termination of service resulting from a change in an annual or other services plan of the Social Services Block Grant program or other state program or policy when those decisions have provided for adequate public notice;c. A provider organization has given adequate notice to all clients that service(s) are to be terminated at the end of a specified period due to discontinuance of the program, lack of funding, etc.;d. Documented circumstances in the case which would constitute a danger to the provider organization's staff or other clients;e. A change in the method of service delivery when the identified need is one which can be met in one of several alternative methods.iv. Provider organizations shall retain all notices to discontinue terminate, suspend or reduce services in the clients' files.c. Provider Agency Conferences: i. A written request for a conference with the provider organization must be received by the provider within 10 calendar days of the individual's receipt of the agency decision. Unless otherwise established, it shall be presumed that receipt occurred on the third day after mailing by the provider.ii. When a request for a conference is received, the provider organization's director or delegated agency official shall notify the client in writing of the date, time, and place of the conference within 10 days of receipt.iii. If the written request for a conference is received by the provider within the time frame prescribed in #1 above, services shall be continued -throughout the agency conference process.iv. At the conference, the client may present any evidence or information which he/she believes may affect his/her eligibility for, or the amount or type of services requested.v. The client may ask any questions that he/she has regarding the provider's decision on services.vi. The provider organization shall issue written notification of its decision within ten (10) calendar days of the conference.vii. If the client is not satisfied with the provider decision, he/she may request a Departmental hearing.d. State Agency Hearing:i. Written client requests for state agency hearings shall be accepted by the Department for 30 calendar days from the initial notice of the action.ii. Services shall be continued throughout the entire hearing process when the written requests for a provider agency conference and a state agency hearing are received within ten (10) calendar days of the individual's receipt of notification.iii. When a state agency hearing request is received within the time frame stated in #2 above, the Office shall notify the provider immediately of their responsibility to continue service until the state agency hearing decision is rendered.iv. Within ten (10) calendar days of receipt of a valid request for a hearing, the client and provider organization shall be notified in writing of the date, time, and place of the hearing, and given information on the hearing process and procedures. In no instance will a hearing be scheduled earlier than ten (10) calendar days from notice.v. The Department shall dismiss requests for state agency hearings when: a. The request is not received within the specified time period;b.The request is withdrawn by the client or his/her representatives; c. The client or his/her representative fail to appear at the scheduled hearing without good cause, as determined by the hearing officer.vi. If a client and/or provider organization desires legal or other representation at a hearing, they shall be responsible for any legal or other costs of representation incurred, unless otherwise approved by the Officevii. The state agency hearing shall be conducted in accordance with the current Administrative Procedure Act promulgated rules for state agency hearings.e. Judicial Review Further review of any action taken under this section shall be subject to the Maine Rules of Civil Procedure, 8OC.
10-148 C.M.R. ch. 5, § III