Appendix B OSAH Responsibilities | Medicaid

Georgia Division of Family and Children Services
Medicaid Policy Manual

Policy Title:

OSAH Responsibilities

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 Office of State Administrative Hearings (OSAH) has specific duties regarding the conduct and requirements of a hearing, which are conducted consistent with Georgia’s Administrative Procedure Act, other applicable laws, regulations, and OSAH’s Administrative Rules of Procedure.

Basic Considerations

OSAH Actions and Responsibilities

The OSAH initiates the following actions as needed:

provides, at least ten (10) days prior to the hearing, advance written notice to all involved parties to permit adequate preparation of the case
changes the time and/or location of the hearing upon its own motion or for good cause shown by the applicant/recipient (A/R)
adjourns, postpones, or reopens the hearing for receipt of additional information at any time prior to the mailing of the state’s decision on the case
conducts a group hearing, consolidating cases where the sole issue involved is one of state and/or federal law, regulation or policy
conducts a single hearing for multiple programs, if determined appropriate
conducts the hearing on a newly emerged issue if, at the hearing it becomes evident that the issue involved is different from the one on which the hearing was originally requested
orders an independent medical assessment or professional evaluation, at agency expense, if the hearing involves medical issues such as a diagnosis, an examining physician’s report or a medical review team’s decision. The source of the evaluation must be satisfactory to the A/R and the agency.

Members of the medical review team may not be subpoenaed.
determines numbers of persons who may attend the hearing
denies or dismisses a hearing request.
utilizes only the facts or opinions that are evidence of record or which may be officially noticed and are, therefore, subject to the rights of objection, rebuttal, and/or cross examination by the involved parties. The Administrative Law Judge (ALJ) is the sole “trier of facts”.
makes a decision within ninety (90) days from the date of the receipt of the written request for a hearing
mails the hearing decision to all involved parties
informs the claimant of appeal rights and that an appeal may result in a reversal of the final hearing decision.

The Hearing Decision

Hearing decisions become a part of the case record and must meet the following criteria:

comply with all federal and state laws, regulations and policies
take into consideration only those issues directly related to the action appealed
be based on evidence and other material introduced at the hearing
be accessible to the public, with the identity of the A/R protected

The Administrative Law Judge’s Official Record

The Administrative Law Judge (ALJ) official record must meet the following criteria:

contain the substance of what transpired at the hearing and all papers and requests filed in the official proceedings
be available to the A/R or its representative by appointment for copying and inspection
requesting a response to any additional material or documentary evidence from the agency
basing the final decision on the record from the ALJ.
notifying the A/R in writing of the final decision and the right to a judicial review.

Use the following chart to determine whether to continue, reinstate or change benefits pending an initial hearing decision.

CHART B.1 - CONTINUATION OF BENEFITS PENDING A FINAL HEARING DECISION
IF THE A/R REQUESTS A HEARING	THEN, WHILE THE INITIAL HEARING DECISION IS PENDING,
within 14 days of the date of the timely notice and requests continuation of benefits	continue Medical Assistance at a level equivalent to the level prior to the date of the timely notice. Continue the vendor payment and patient liability or cost share, if applicable.
within 14 days of the date of the adequate notice and requests continuation of benefits	reinstate Medical Assistance at a level equivalent to the level prior to the date of the adequate notice. Reinstate the vendor payment and patient liability or cost share, if applicable.
and claims Good Cause for not appealing during the 14-day timely notice period	Reinstate benefits only upon approval by the ALJ.
and the Medically Needy budget period has ended	determine spend-down for a new budget period and allow the A/R to submit medical bills.
and a change, other than a mass change, affecting eligibility occurs	change the benefits appropriately unless the A/R requests a hearing on the subsequent change and requests continuation of benefits. Notify the ALJ.
and a mass change is required	change the benefits appropriately and notify the ALJ. Continuation or reinstatement following a mass change is appropriate only if the ALJ determines that the mass change was incorrectly applied.

Use the following chart to determine whether to continue, reinstate or change benefits pending an appeal of an initial hearing decision

CHART B.2 - CONTINUATION OF MEDICAL ASSISTANCE PENDING AN APPEAL OF A FINAL HEARING DECISION
IF THE A/R REQUESTS AN APPEAL OF THE FINAL HEARING DECISION	THEN, WHILE THE APPEAL OF THE FINAL DECISION IS PENDING
within 14 days of the final hearing decision and requests continuation of benefits	continue Medical Assistance, including vendor payment and cost share or patient liability, previously continued pending the final hearing decision.
and claims Good Cause for not appealing the final hearing decision within 14 days of the decision	reinstate benefits, including vendor payment and patient liability/cost share, only upon approval by the DFCS Medicaid Policy Unit.
and the Medically Needy budget period has ended	determine eligibility for a new budget period and allow the A/R to submit medical bills.
and a change, other than a mass change, affecting eligibility occurs	change the benefits appropriately and notify the DFCS Medicaid Policy Unit.
and a mass change is required	change the benefits appropriately and notify the DFCS Medicaid Policy Unit. Continuation or reinstatement following a mass change is appropriate only if the DFCS Medicaid Policy Unit determines that the mass change was incorrectly applied.

CHART B.3 - ADJUSTMENT OF MEDICAL ASSISTANCE BASED ON THE DECISION FROM AN FINAL HEARING OR THE APPEAL OF AN FINAL HEARING
IF BENEFITS WERE	THEN
continued or reinstated prior to the hearing or appeal and the decision is favorable to the A/R	continue Medical Assistance benefits. Take action to issue any corrective vendor payment as authorized by the ALJ or Superior Court.
not continued or reinstated prior to the hearing or the appeal and the decision is favorable to the A/R	approve Medical Assistance retroactively and issue corrective vendor payments as directed by the ALJ or DFCS Medicaid Policy Unit.
continued or reinstated prior to the hearing or the appeal and the decision is favorable to the agency	provide adequate notice and reflect the decrease in benefits the month following the decision. Do not advise the A/R that s/he may request another hearing, as the hearing decision serves as adequate notice of appeals rights.
not continued or reinstated prior to the hearing or the appeal decision is favorable to the agency	maintain case in current status.