Appendix B Hearings | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

Hearings

Effective Date:

July 2024

Chapter:

Appendix B

Policy Number:

N/A

Previous Policy Number(s):

MT 60

Updated or Reviewed in MT:

MT-72

Requirements

The fair hearing process entitles an applicant or recipient (A/R) to an impartial hearing, upon his/her request, to appeal an agency action or inaction.

Basic Considerations

Notification of the Right to a Fair Hearing

The A/R must be informed, in writing, of his/her right to a fair hearing, the methods of requesting a hearing, and that assistance with completing the required forms will be provided, if requested. The A/R must be informed of this right at the following times:

at application
when any action is taken that affects benefits
when the A/R requests a restoration of lost benefits

Request for a Hearing

A request for a hearing, either orally or in writing, is an expression by the A/R or his/her authorized representative (AREP) of the desire for an opportunity to present the case to a reviewing authority.

Authorized representative is defined as a person or organization designated by the A/R or beneficiary to assist with the application, renewal of eligibility and other ongoing communications with the agency. Elected AREP may have verbal or written designation. If the designation is written, the applicant’s signature is required. Court orders establishing legal guardianship or a valid power of attorney is to be treated as written designations.

DHS Form 5459 Release of Information does not assign the entity or individual as the AREP and does not give permission to act on client’s behalf.

A request for a hearing may be submitted to any Division of Family and Children Services (DFCS) office.

DFCS is prohibited from disclosing Personally Identifiable Information (PII) or Protected Health Information (PHI) to unauthorized individuals. Therefore, DFCS will not disclose, discuss or allow access to the A/R’s PII or PHI without authorization. DFCS processes hearing requests that are submitted on behalf of an A/R when DFCS is provided valid legal authorization.

Assistance, such as language assistance, must be provided to the A/R and the AREP, if requested, with completing the necessary document(s).

A qualified interpreter must be provided for any A/R and the AREP in the preferred language identified by the A/R (or the AREP), so that DFCS' hearing procedures are explained in a language understood by the A/R.

The A/R must request a hearing within thirty (30) days of notification of the decision with which s/he disagrees (42 C.F.R. § 431.221(d)).

In the event an oral request is made, the A/R must submit a written request within fifteen (15) days of the original request.

All hearing requests will be forwarded to OSAH, regardless of when the request was received. For untimely requests received, DFCS' hearing representative will enter into evidence the untimely policy and the Administrative Law Judge (ALJ) will determine if good cause exists. If DFCS fails to submit a hearing request to OSAH within 30 days after DFCS receives such request, the applicant, recipient, or authorized representative can file a petition directly with OSAH to request a hearing (referred to as a Direct Petition).

OSAH is responsible for scheduling hearings and notifying the parties (the Petitioner and the DFCS hearing representative) of the date, time, and location of the hearing.

A hearing request received from an A/R who is planning to move out of state before the hearing decision is reached may be expedited so that a decision may be issued before they move.

Women’s Health Medicaid (WHM)

Upon receipt of a WHM hearing request, DFCS will follow the standard hearing process. All hearing notifications must be e-mailed to DCH, Shameeka Miller at shameeka.miller@dch.ga.gov. DCH will notify Department of Public Health on all second-level reviews that have been scheduled for a hearing.

Continuation of Benefits

Upon the A/R’s request, Medicaid eligibility and patient liability/cost share may be continued, provided the request for continuation is received within 10 days of the date of timely or adequate notice. Refer to 2701 Notification and Chart B.1, Continuation of Medicaid Pending a Hearing Decision.

The Department of Community Health (DCH) reserves the right to require the A/R to repay continued benefits if s/he loses the hearing.

Allowance should be made in the event the A/R’s reports late receipt of notification due to mail processing time. If the A/R provides the envelope in which the notice was received, allow 12 days from the U.S. Postal Service date stamp to determine if benefits are to be continued. If the A/R cannot provide the envelope in which the notice was received, allow 14 days from the date on the notice to determine if benefits are to be continued. In the event the 14th day is a weekend or holiday, allow until the close of business on the first workday following the 14th day.

EMA

Effective January 1, 2006, continuation of benefits for ongoing EMA services pending a hearing will not be allowed as no future dates of service for EMA are applicable per policy.

SSI

SSI recipients who have had SSI benefits terminated and who wish to continue Medicaid pending the outcome of an appeal of SSI/Medicaid may do so. This should occur in the interface between SSA and DCH. However, if the SSI A/R reports that this has not occurred and that Medicaid benefits have terminated, have the A/R provide written verification from SSA that they have appealed the SSI termination. Contact your Medicaid Field Program Specialist to have the A/R’s eligibility restored pending the outcome of the appeal. The Program Specialist will need to provide the written proof to DCH to have the A/R updated in DCH’s system. If the A/R only wants to appeal the Medicaid termination and not the SSI, there are no Medicaid benefits to continue since the Medicaid went along with the SSI. DFCS should complete a CMD on the A/R and approve or deny as appropriate. At that point, the A/R may make an appeal of the Medicaid benefits denied through DFCS.

The Hearing

An OSAH Administrative Law Judge (ALJ) conducts hearings. See exceptions in chart below. The hearing includes consideration of the following:

any agency action, including the following:
- denial or approval of an application
- calculation of patient liability or cost share
- termination of benefits
- change in COA
- change in patient liability or cost share
the agency’s delay in action or failure to act, including:
- delay in application processing
- failure to act, or delay in action on a change
  
  The list above is not inclusive.

AGENCY HEARINGS
Program	Hearing Agency
SSI money payment	Social Security Administration (SSA)
SSI Medicaid Denial/Termination	OSAH
DFCS Medicaid COAs	OSAH
Level of Care (LOC) for Katie Beckett	Department of Community Health Legal Services
Breast & Cervical Cancer Program	OSAH
Medicare Part D Low Income Subsidy	Social Security Administration (SSA)
SMEU	OSAH

State law prohibits the ALJ from providing legal advice to any party, including the state agency. As such, OSAH cannot assist the agency or the petitioning A/R in determining who should be present as witnesses at the hearing or what evidence is necessary to establish the case.

An ALJ shall have all the powers of the ultimate decision maker in the agency with respect to a contested case. Hearing decisions are based on evidence introduced at the hearing. Hearing decisions specify the reason for the decision, which includes findings of fact, conclusions of law, and a disposition of the case.

Hearings: Rights and Responsibilities of the A/R and DFCS

The A/R or his/her AREP has the right to the following:

examine the contents of the case record and all pertinent documents and records prior to the hearing.

Certain confidential case record information may not be released to or viewed by anyone, including the A/R. Refer to Section 2010 Confidentiality and 2011 Health Information Portability and Accountability Act of 1996 for additional information, including what may not be released and penalties for unauthorized release.

Confidential information that is protected from release and other documents or records that the A/R may not contest or challenge may not be presented at the hearing.

present the case with or without the aid of a representative, including legal counsel, a relative, friend or other spokesperson
request assistance from the agency for transportation to/from the hearing.

The A/R and DFCS have the right to the following:

bring and/or subpoena witnesses
establish all pertinent facts and circumstances
present arguments without undue interference
question or refute any testimony or evidence, including the opportunity to question and cross-examine adverse witnesses.

DFCS has the responsibility for the following:

ensuring the presence at the hearing of staff members with direct knowledge of the facts in dispute
ensuring that all relevant agency records and copies are legible and available as evidence
ensuring that non-agency witnesses and records are present, either voluntarily or by subpoena.

Withdrawal, Cancellation or Postponement of the Hearing

The withdrawal, cancellation or postponement may be requested by the A/R or his/her AREP and may be made orally or in writing.

If received 5 days or less from the scheduled hearing date, notify the Administrative Law Judge contact as indicated on the appointment notice by facsimile or electronic mail. These should include the docket number.

The Final Hearing Decision

The Final Hearing Decision is issued within ninety (90) days from the date the written request for a hearing is received by the agency, except in the event of a postponement or continuance.

No action may be taken to reduce or terminate Medical Assistance until the decision is final.

Effective May 8, 2018, in accordance with O.C.G.A. Section 50-13-41(c), every decision by an OSAH ALJ is a final decision that may only be appealed by filing a petition for judicial review, with proper service in accordance with the applicable law, in the Fulton County Superior Court or in the Superior Court in the county of residence of the petitioner.

See Appendix B Appeal in this section for final decision appeal information and procedures.

Procedures

Processing a Hearing Request

Step 1

Upon receipt of a hearing request, follow the steps below.

Within three (3) business days of agency’s receipt of hearing request,review the record to determine the following:

Was correct action taken? If not, correct the case and notify the A/R. S/he may choose to withdraw the request for a hearing.
Was a Continuing Medicaid Determination (CMD) completed?
Is the A/R eligible based on all other points of eligibility with the exception of the one at issue?

Step 2

Within three (3) business days of agency’s receipt of hearing request, discuss the complaint with the A/R or his/her AREP prior to submitting the hearing request to OSAH (using the OSAH Form-1 and the items listed in Step 4, below), to ensure that a hearing is necessary.

If a mutually satisfactory decision is reached, the A/R may choose to withdraw the request for a hearing – verbally or in writing. If a verbal withdrawal is received, the OSAH Form 1 will not be submitted and the agency will send correspondence to the A/R confirming the verbal withdrawal.

How to handle withdrawals of hearing requests after the agency has transmitted the OSAH Form-1.

Verbal withdrawals: If the A/R contacts DFCS to verbally withdraw his/her hearing request after the agency has sent the OSAH Form-1, Fair Hearing Specialist will inform the A/R to contact OSAH to request that the A/R’s hearing be removed from the OSAH hearing calendar. No written correspondence will be sent to A/R if the verbal withdrawal is received after the 3rd business day.
Written withdrawals: If the A/R contacts DFCS by submitting a written withdrawal of his/her hearing request after the agency has sent the OSAH Form-1, the Fair Hearing Coordinator will forward the A/R’s written withdrawal to OSAH (via physical letter or email) and copying the A/R to all related correspondence.

Step 3

Inform the A/R that timeliness in filing the hearing request affects continuation or reinstatement of benefits and that late filing may result in denial of the request for a hearing.

Step 4

If a mutually satisfactory solution cannot be obtained and the A/R does not submit a hearing request withdrawal, submit the following documents to OSAH within five (5) business days of receipt of the hearing request, even if unable to contact the A/R to discuss the complaint.

The information should be sent to:

Office of State Administrative Hearings (OSAH)
225 Peachtree Street NE
Suite 400, South Tower
Atlanta, GA 30303

Referral for hearing request can be sent electronically from the Fair Hearing Coordinator to the OSAH clerk’s office (Jason Rouse, Chief Clerk - jrouse@osah.ga.gov; Devin Hamilton, Deputy Chief Clerk - devinh@osah.ga.gov).

Include:

Form 118, Request for Hearing, or any written request for hearing presented by the A/R
Decision notice which pertains to the action in dispute
OSAH Form 1-Medicaid

Make sure that any available contact numbers for the A/R are included on the OSAH-Form-1.

It is the responsibility of the case manager to present the following documents at the hearing:

the application or renewal for assistance related to the matter(s) in dispute
all records documenting or verifying facts, including records of telephone conversations, interviews, etc., which pertain to the action in dispute and any other materials that were made part of the case file in the normal course of business and on which the agency relied for the action taken, including budgets

subpoenas for individuals and/or documents prepared for the ALJs. If subpoenas are required for documents, include the type of document, the document custodian’s name and address

The request for subpoena form must be completed setting forth the relevance of the testimony/documents sought. This form must be attached to the subpoena sent to OSAH. Copies of the request form and the subpoena must be provided to all parties involved in the hearing. The subpoena, after being signed by the ALJ, is returned to DFCS for personal service on the witness or for mailing to the witness via certified mail. A copy of a form or sample subpoena is available on OSAH’s website.

copy of all policy and regulation(s) relied upon in reaching the action in dispute.

Step 5

Determine if the A/R is entitled to continued or reinstated benefits. Continue or reinstate Medicaid benefits if allowed. Refer to Chart B.1 for continuation of benefits.

Inform the A/R that a request for continuation or reinstatement of patient liability (PL) or cost share (CS) pending a hearing decision may result in an increase of the A/R’s financial responsibility if the hearing decision is adverse to the A/R or a decrease of the A/R’s financial responsibility if the hearing decision is favorable to the A/R.

If the hearing request submitted by or for the A/R does not indicate that the A/R has waived continuation of benefits, assume continuation is desired.

Step 6

Allow the A/R opportunity to examine documents and records that will be used in the hearing. Allow the A/R’s representative the opportunity to examine these documents if the A/R signs a Form 5459, Authorization to Release Information.

Step 7

Report any changes in the circumstances related to the hearing, including address changes, OSAH.

Forward any subsequent documents received concerning the hearing to OSAH.

PeachCare for Kids® and Planning for Healthy Babies®

The RSM Group staff will process all PeachCare for Kids® and Planning for Healthy Babies® (P4HB) administrative eligibility reviews and fair hearings. The RSM Group will follow the procedures below:

Step 1	Requests for Administrative Eligibility Reviews or Hearings must be submitted within thirty (30) days of the written notification in which parent or A/R disagrees. If verbal request is made, the parent or A/R must submit a written request within fifteen (15) days of the original request. If the written request is not received, no further action is required. Administrative Eligibility Review of Fair Hearing requests can be submitted by the parent or A/R through fax: (912) 632-0389, mail: P.O. Box 786, Alma, GA 31510, email: RSM South Hub at rsm.mailfax@dhs.ga.gov or received by the Division of Family and Children Services (DFCS) and forwarded to RSM for processing.
Step 2	The administrative Eligibility Review request, client(s) and case will be reviewed by an impartial RSM caseworker. Eligibility or renewal should be completed, if possible. The RSM caseworker will notify the parent or A/R in writing of the outcome and request the parent or A/R to submit a withdrawal. RSM will document using the case notes in GA Gateway and upload in document management the request and any related items. Worker will create case notes with adequate documentation of the current case status and resolution. Document Management uploading the admin information; make sure to put a comment in the box: PCK or P4HB Admin Review Only.
Step 3	If the case is not approved or not resolved and the parent or A/R has not withdrawn the request, RSM will attempt to contact the parent or A/R by phone, email, or mail to review case and to request withdrawal.
Step 4	If the case cannot be resolved or withdrawn, then a Fair Hearing Request Notice will be manually mailed or emailed to the parent or A/R and uploaded into Gateway by RSM. The notice will notify the parent or A/R to contact the agency within 10 days from the date of the letter to request an OSAH hearing. If no response is received, the Administrative Eligibility Review is considered complete after the 10th day and a case note will be placed in Gateway by RSM. No further action is required.
Step 5	If customer responds and would like to proceed with an OSAH Hearing, the procedures for Medicaid hearings must be followed. RSM must upload all related items into Document Management under Hearings and document in Case Notes. DHS legal is sent the information and PCK or P4HB Hearing inbox should be copied on all OSAH referrals. Continue with above Steps 1 through 7 of Processing a Hearing Request.

Implementation of a Final Hearing Decision

Follow the steps below to implement a hearing decision.

Step 1	Determine whether the decision is favorable to the A/R or the agency and adjust the A/R’s ongoing benefits, including patient liability or cost share, if necessary.
Step 2	Notify the A/R of the action taken via manual notice. The notice must indicate that the action taken is the result of the hearing decision. Include each month’s circumstance and eligibility status. Do not include information regarding further appeals.