N.M. Admin. Code § 8.100.970.8 - FAIR HEARINGS
A. A
household aggrieved by an adverse action taken by the department or NMHIX that
affects the participation of the household in a department administered public
assistance program or in the New Mexico health insurance exchange, if
applicable, may appeal the department's or NMHIX's decision by requesting a
fair hearing in accordance with federal and state laws and regulations.
(1) Medicaid recipients wanting to request a
fair hearing due to termination, modification, reduction or suspension of
services must do so in accordance with any applicable federal and state laws
and regulations, including
8.200.430.12 NMAC and 8.352 NMAC,
et seq.
(2) Fair hearings related
to adverse actions by NMHIX shall be held in accordance with any applicable
federal and state laws and regulations, including those set forth in 45 CFR 155
Subpart F.
B. A
household may designate an authorized representative to request a hearing on
its behalf and to represent them during the fair hearing process. The claimant
or their authorized representative must complete a request for access to a case
record each time they wish to have access to the record outside what is
provided to the claimant in the summary of evidence (SOE). If the claimant
wishes to have their authorized representative review the record in their
absence, the claimant must provide formal documentation authorizing the named
individual(s) to access the identified case information for a specified purpose
and time frame.
C.
Hearing
rights: Each household has the right to request a fair hearing and:
(1) to be advised of the nature and
availability of a fair hearing and an ARC, if applicable;
(2) to be represented by counsel or other
authorized representative of the claimant's choice;
(3) to receive reasonable assistance in
completing procedures necessary to request a fair hearing; and
(4) to receive a copy of the SOE and any
document contained in the claimant's case record in order to prepare for the
fair hearing in accordance with Subsection B of
8.100.970.8 NMAC; the department
shall forward the SOE and any other document(s) submitted to the fair hearings
bureau for admission into the fair hearing record to the claimant's authorized
representative once the department or NMHIX becomes aware that an authorized
representative has been designated by the claimant;
(5) to have a fair hearing that safeguards
the claimant's opportunity to present a case;
(6) where applicable/for non-NMHIX matters,
to elect to continue to receive the current level of benefit, provided the
request for hearing is received by the department before the close of business
of the 13th day immediately following the date of the notice of adverse action;
a claimant that elects to continue to receive the same level of benefit pending
the fair hearing decision shall be informed that a hearing decision in favor of
the department may result in an overpayment of benefits and a requirement that
the household repay the benefits; a claimant may waive a continuation of
benefits pending the outcome of the fair hearing;
(7) in matters involving NMHIX, to be
considered eligible while an appeal is pending, in accordance with the
provisions of
45 CFR §
155.525;
(8) to have prompt notice and implementation
of the final fair hearing decision; and
(9) to be advised that judicial review may be
invoked to the extent such review is available under state or federal law;
and
(10) in matters involving
NMHIX, to be advised that a second-tier appeal to the United States department
of health and human services is available.
D. The department and NMHIX will neither
provide representation for, nor pay for any costs incurred by a claimant or the
authorized representative in preparation for, or attendance at an ARC, fair
hearings or judicial appeals.
E.
Notice of rights:
(1) At the time
of application for assistance, the department shall inform each applicant of
the applicant's right to request a fair hearing if the applicant disagrees with
an action taken by the department. In matters involving NMHIX, NMHIX shall
provide notice of appeal rights and appeal procedures, including the right to
request a fair hearing, at the time that the applicant submits an application
and the notice of eligibility determination is sent under
45 CFR §§
155.310(g),
155.330(e)(1)(ii),
155.335(h)(1)(ii),
and
155.610(i).
The applicant may choose to receive the notice by mail or in electronic
format.
(2) The notice shall inform
the applicant of the procedure by which a fair hearing may be requested and
that the claimant's case may be presented by the claimant or an authorized
representative.
(3) The department
shall remind the household of its right to request a fair hearing any time the
household expresses disagreement with an action taken on its case by the
department.
(4) Each county office
shall post a notice of the right to request a fair hearing and an ARC, and a
copy shall be given, upon request, to any person that has requested a
hearing.
(5) Each notice provided
to a claimant pursuant to this section shall include a statement that free
legal assistance, by an individual or organization outside of the department,
may be available to assist with the fair hearing process.
(6) A claimant may request special
accommodations for a disability or a language or speech interpreter be
available during an informal resolution process, a fair hearing or ARC. An
interpreter or special accommodations shall be provided by the department or
NMHIX, as applicable, at no cost to the claimant. A request for a language
interpreter, a speech interpreter or other disability accommodation must be
made within 10 days of the date of the fair hearing. If an interpreter or
disability accommodations are not requested timely, the claimant can request
postponement of the hearing in accordance with Subsection B of
8.100.970.10
NMAC.
F.
Special
provisions pertaining to mass changes: Special provisions apply in
situations involving mass changes. These provisions are contained at
8.100.180.12 and 15 NMAC,
8.139.120.13 NMAC, 8.139.500.8 and
9 NMAC, 8.106.630.10 and 11 NMAC,
8.102.501.9 NMAC and
8.102.630.10 NMAC.
G.
Continuing benefit for cash
assistance: If a claimant who is a cash assistance recipient requests a
fair hearing before the close of business of the 13th day immediately following
the date of the notice of adverse action, the claimant may elect to waive or
continue receiving the same amount of cash assistance and services issued
immediately prior to the notice of adverse action until a final decision is
issued. If there is no indication that the claimant has waived a continuation
of benefits, the department will assume a continuation of benefits is desired.
The household is required to comply with the reporting and renewal provisions
at 8.102.120 NMAC and 8.106.120 NMAC. Cash assistance recipients are to
continue compliance with the NMW compliance requirements at 8.102.460
NMAC.
H.
Continuing SNAP
benefits: If a claimant who is a SNAP recipient requests a fair hearing
before the close of business of the 13th day immediately following the date of
the notice of adverse action, the claimant may elect to waive or continue
receiving the same amount of SNAP benefits issued immediately prior to the
adverse action until a final decision is issued. If there is no indication that
the claimant has waived a continuation of benefits, the department will assume
a continuation of benefits is desired. The claimant is required to comply with
the reporting and renewal provisions at 8.139.120 NMAC.
I.
Continuing eligibility for a medical
assistance program: If a claimant who is a recipient of a medical
assistance program requests a fair hearing before the close of business of the
13th day immediately following the date of the notice of adverse action, the
claimant may elect to waive or continue receiving the same medical assistance
benefit issued immediately prior to the adverse action until a final decision
is issued. If there is no indication that the claimant has waived a
continuation of benefits, the department will assume a continuation of benefits
is desired. If the hearing is regarding the termination, modification,
reduction or suspension of medical assistance program services, a continuation
of services is governed by all applicable federal and state laws and
regulations, including 8.352 NMAC, et seq.
J.
Continuing eligibility in cases
involving NMHIX: In matters involving NMHIX, eligibility pending appeal
is governed by the provisions of
45 CFR §
155.525.
Notes
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