Utah Admin. Code R414-301-7 - Hearings

(1) The eligibility agency shall provide a fair hearing process for applicants and members in accordance with the requirements of 42 CFR 431.220 through 42 CFR 431.246. The eligibility agency shall comply with Title 63G, Chapter 4, Administrative Procedures Act.

(2) An applicant or member must request a hearing in writing or orally at the agency that made the final eligibility decision. A request for a hearing must be made within 90 calendar days of the date of notice of agency action concerning the Medicaid eligibility decision. The request need only include a statement that the applicant or member wants to present their case.

(3) Hearings are conducted only at the request of a member or spouse, a minor member's parent, or a guardian or representative of the member.

(4) A member who requests a fair hearing concerning a decision about Medicaid eligibility shall receive continued medical assistance benefits pending a hearing decision if the member requests a hearing before the effective date of the action or within 15 calendar days of the date on the notice of agency action.

(5) The member must repay the continued benefits that the member receives pending the hearing decision if the hearing decision upholds the agency action.

(a) A member may decline the continued benefits that the Department offers pending a hearing decision by notifying the eligibility agency.

(b) Benefits that the member must repay include premiums for Medicare or other health insurance, premiums, and fees to managed care and contracted mental health services entities, fee-for-service benefits on behalf of the individual, and medical travel fees or reimbursement to or on behalf of the individual.

(6) The eligibility agency must receive a request for a hearing by the close of business on a business day that is before or on the due date. If the due date is a non-business day, the eligibility agency must receive the request by the close of business on the next business day.

(7) DWS conducts fair hearings for medical assistance cases except those concerning eligibility for Advanced Premium Tax Credits made by the FFM, foster care, or subsidized adoption Medicaid. The Department conducts hearings for foster care or subsidized adoption Medicaid cases. In addition, the Department conducts hearings concerning its disability determination decisions. The FFM conducts hearings concerning determinations for Advanced Premium Tax Credits.

(8) DWS conducts informal, evidentiary hearings in accordance with Sections R986-100-124 through R986-100-139, with the exceptions found in Subsection R986-100-128(17) and Subsection R986-100-134(5). Instead, Subsection (16) concerning the time frame to comply with the DWS decision, and Subsection (17)(c) concerning continued assistance during a superior agency review conducted by DWS, apply respectively.

(9) The Department conducts informal hearings concerning eligibility for foster care or subsidized adoption Medicaid in accordance with Rule R414-1. Pursuant to Section 63G-4-402, within 30 days of the date the Department issues the hearing decision, the applicant or member may file a petition for judicial review with the district court.

(10) DWS may not conduct a hearing contesting resource assessment until an institutionalized individual has applied for Medicaid.

(11) An applicant or member may designate a person or professional organization to assist in the hearing or act as a representative. An applicant or member may have a friend or family member attend the hearing for assistance.

(12) The applicant, member, or representative may arrange to review case information before the scheduled hearing.

(13) At least one employee from the eligibility agency must attend the hearing. Other employees of the eligibility agency, other state agencies, and legal representatives for the eligibility agency may attend as needed.

(14) The DWS Division of Adjudication and Appeals shall mail a written hearing decision to the parties involved in the hearing. The decision shall include the decision, a summary of the facts, and the policies or regulations supporting the decision.

(a) The DWS decision shall include information about the right to request an agency review from DWS and how to make that request.

(b) The applicant or member may appeal the DWS decision to DWS pursuant to Section R410-14-16. The request for agency review must be made in writing and delivered to DWS within 30 days of the mailing date of the decision.

(15) The Department, as the single state Medicaid agency, is a party to fair hearings concerning eligibility for medical assistance programs. The Department has the right to request an agency review of medical assistance hearing decisions given by DWS.

(16) The DWS hearing decision becomes final 30 days after the decision is sent unless DWS conducts an agency review. The DWS hearing decision may be made final in less than 30 days upon agreement of the parties.

(17) DWS conducts an agency review when the applicant or member appeals the DWS decision or if the Department appeals because it disagrees with the DWS decision.

(a) DWS notifies the Department when it conducts an agency review.

(b) The DWS hearing decision is suspended until DWS issues a final decision and order on agency review.

(c) A member who receives continued benefits continues to be eligible for continued benefits pending the agency review decision.

(18) The agency review is an informal proceeding and is conducted in accordance with Section 63G-4-301.

(19) A DWS decision and order on agency review becomes final upon issuance.

(20) The eligibility agency takes case action within ten calendar days of the date the decision becomes final.

(21) Pursuant to Section 63G-4-402, within 30 days of the date the decision and order on agency review is issued, the applicant or member may file a petition for judicial review with the district court. Failure to request an agency review negates this right to a judicial appeal.

(22) Members are not entitled to continued benefits pending judicial review by the district court.

Notes

Utah Admin. Code R414-301-7

Amended by Utah State Bulletin Number 2023-08, effective 3/30/2023