Medical Assistance (MA) Expedited Fair Hearing, OPS170904 (Published September 29, 2017)
The client or his representative may request a fair hearing by:
completing and signing the appeal section of any notice;
sending a written or faxed request to the CAO;
telling the CAO; or
NOTE: The client must follow up with a written request within 3 days of the oral request unless it is a SNAP appeal. If a written request is not required or received, the CAO should document the oral request in a memo and send the memo to BHA.
sending a written request to another provider or agency which notified the client of a decision. The client must request the fair hearing from the agency or provider which notified him of the decision. The agency or provider will forward the request to BHA.
NOTE: Commonwealth Court decided that certain firms which assist MA clients are not “collection agencies” and may represent clients under power-of-attorney in the appeal process. (Nolan v. Department of Human Services, 673A.2d 413 (Pa.Cmwlth 1995)).
A faxed request for a hearing and the faxed Power of Attorney form are acceptable. Original copies are not required.
55 Pa. Code § 275.4(h)(2) 7 CFR 273.15(h)
The CAO, agency, or provider will help the client to request the hearing as follows:
Clearly explain the reason for the action or decision which the client is questioning.
Provide an interpreter if needed.
NOTE: If the client needs an interpreter/transliterator at the hearing because of Limited English Proficiency (LEP) or a hearing impairment, BHA will arrange for an official interpreter/transliterator. The client may bring a friend or relative to assist the client at the hearing, but the interpreter provided by BHA will be the official interpreter.
Explain the procedure.
Help write the request or fill out forms.
Advise the client that a friend, relative, attorney, legal services, or other spokesperson may represent him and include this individual in all discussions related to the appeal.
Provide case record materials at the client's request.
Case information related to an appeal must be made available to an attorney or advocate who contacts a CAO if any of the following happens:
1. an authorization signed by the client is provided.
2. the appeal form or another form indicates that the attorney or advocate is representing the client
3. the client calls the CAO to say that the attorney or advocate is representing the client.
4. the CAO calls the client who confirms that the attorney or advocate is representing the client.
5. the CAO knows the attorney or advocate who provides facts about the case, and the CAO can trust the claim that the attorney or advocate is representing/helping the client.
Case information released to an attorney or advocate based on 3, 4 or 5 above requires case narrative
Procedures in Chapter 930, Safeguarding Information, must be followed for any other request for case record information.
NOTE: The CAO will provide materials, free of charge, which are related to the issue being appealed.
Upon receipt of a request for a fair hearing, the CAO, agency, or provider will:
Date stamp all appeals received.
Identify whether the appeal is expedited (i.e. Community Choice) and follow the expedited appeal process below (See Section 870.211, Expedited Community Choice Appeals Procedures).
For SNAP - Date stamp the written request. If the request is made orally, the CAO will write a memo and date stamp it with the date of the oral request. The client is not required to write his request. Attach a copy of the notice for the proposed action.
55 Pa. Code § 275.4(h)(3) 7 CFR 273.15(b)
For Cash Assistance, Medical Assistance, and Services - Date stamp the written request. The request must specify the action being taken and be signed by the client. If an oral request is made, help the client write his request. If the oral appeal is not written and signed by the client within three working days after the oral appeal is made, the Bureau of Hearings and Appeals (BHA) may dismiss the appeal. The memo of the oral request must be forwarded to BHA for disposition.
Review the request to be sure it includes identifying information, such as the case number, complete address, and name of the CAO. The CAO should assess the appellant’s need for LEP services and enter results on the appeal coversheet and in MAPPER/HATS.
Enter the appeal in MAPPER/HATS. Send the fact sheet as described in Section 870.5 and send the hearing request including a complete version of all adverse action notices including attachments and English translations if applicable to BHA within three working days from the date it is received and date stamped. Include the envelope in which the appeal came (or a copy with the postmark), a completed appeal cover sheet and applicable OARS screens for overpayment appeals.
Exception: Send an appeal of a denial of payment for an abortion to BHA within one working day or less. Ask this client if she is willing to waive her right to notice 10 days prior to the date of the hearing and if she agrees to a telephone hearing instead of a face-to-face hearing. These waivers will allow BHA to make a decision within 30 days. The CAO will write the client's decision about the waivers and the phone number for the client on the appeal request.
If the hearing request is mailed to the CAO, make a copy of the postmarked envelope for the case record. Send the postmarked envelope with the request to BHA. BHA considers the date of the date stamp as the filing date. BHA considers the postmarked date as the filing date only if it makes the appeal timely filed.
If the hearing request is hand-delivered or completed in the CAO, BHA considers the date stamp as the filing date.
If the hearing request is oral, the date the request is made is the filing date. Send a copy of the agency’s notice with the memo, if applicable.
Reminder: For other than SNAP cases, the CAO will request the appellant to submit the appeal request in writing to BHA.
Review the client's appeal to verify that the CAO's action was correct. If the action is incorrect, take corrective action. If the corrective action involves a payment, it may be retroactive to the date of the incorrect action. Send the client a notice explaining the action.
NOTE: Corrective action or payment does not interfere with or affect the client's right to proceed with the appeal. If the client is satisfied with the corrective action and withdraws his request for a hearing, the CAO will contact BHA as soon as the CAO receives the written withdrawal signed by the client. The CAO will forward the signed written withdrawal to the BHA office where the ALJ is located if the appeal is scheduled. If the appeal is not scheduled, the CAO must enter the withdrawal into MAPPER/HATS and forward the withdrawal to BHA.
55 Pa. Code § 275.4(h)(3)(ii) 7 CFR 273.15(b)
Offer the client the opportunity for a face-to-face or telephone prehearing conference to attempt to resolve the appeal. See Section 870.13, Prehearing Conference.
When the adverse action is the result of the client's failure to keep an appointment for a recertification, redetermination or renewal, or ETP interview, and the client requests another appointment, the CAO will schedule an appointment to attempt to resolve the appeal. In the interim, the appeal process proceeds.
Determine if the client has provided new or additional or acceptable verification of the eligibility factor at issue in the appeal. If the verification shows that the client met the eligibility factor as of the effective date of the adverse action, the CAO will restore benefits retroactive to the date of termination, denial, reduction, or suspension, provided all other conditions of eligibility are met.
NOTE: If the verification submitted shows the client has met eligibility factors but the date is after the effective date of the adverse action, benefits will begin or be reinstated on the date eligibility is verified.
Example:
Mrs. Jones failed to keep a scheduled redetermination interview and to verify the family's eligibility for TANF, SNAP, and MA. The CAO sent a PA/FS 162-A dated January 7, advising Mrs. Jones that her benefits would be terminated effective January 21. On January 25, Mrs. Jones filed a timely appeal. On February 2, prior to the hearing, Mrs. Jones provided acceptable verification establishing her family's continued eligibility for benefits. Since Mrs. Jones provided verification to establish her eligibility as of the effective date of the closing, the CAO restored benefits retroactive to January 21.
The CAO will make available to the client and his representative, and will provide copies as requested, no later than five calendar days prior to the date of the scheduled hearing including hearings scheduled for expedited appeals:
All information which the CAO intends to use as evidence.
The names of CAO staff who expect to participate.
The fact sheet.
All exhibits.
NOTE: Information mailed to the client and his representative must be received no later than five calendar days prior to the scheduled hearing.
55 Pa. Code § 275.4(h) 7 CFR 273.15(p)
NOTE: The CAO will notify other agencies/bureaus about appeals that require documentation and/or representation for the hearing from that agency. This includes Bureau of Employment and Training contractors and the Bureau of Child Support Enforcement. The CAO will provide the names of the staff member(s) from other agencies who will participate in the hearing and any documentation from the agency that will be presented at the hearing. This information must be provided to the client and/or his representative at least five days prior to the date of the scheduled hearing.
NOTE: If the CAO fails to submit the exhibits to the client and his representative five days prior to the hearing, the CAO may:
Lose the hearing.
Be denied the ability to submit the exhibits at the hearing.
NOTE: In specific instances, the CAO may request an exemption to the five-day time frame. The request must be processed through the Executive Director.
If there are any materials which the CAO believes should not be released because of confidentiality requirements, the CAO will send BHA a written summary including:
the decision or action that the client is appealing and the reasons for it;
the specific document or subject matter the client wants to examine; and
The reasons for withholding the material.
The CAO will give the client a copy of the summary. The client may submit to BHA his reasons for requesting the materials.
The ALJ will determine if the material is relevant and if the CAO should give it to the client. This decision cannot be appealed. If the CAO obtained information from the Office of General Counsel, any information provided is protected by client/attorney privilege and considered confidential. The CAO will not make the information part of the client record and will not give it to the client or any other individual or introduce it as evidence in a hearing. If the CAO specifically requests a document from the Office of General Counsel to use as evidence, that document is provided to the client.
NOTE: Requesting a decision from BHA does not negate the responsibility to provide materials to the client and/or representative no later than five days prior to the date of the hearing.
The client has the choice of submitting a request for an appeal hearing under the existing process or under an expedited process. The CAO will provide written notification of the option of an expedited appeal process to all clients whose Medicaid eligibility is denied or terminated.
NOTE: Even though the Waiver programs administered by the Office of Mental Retardation (Consolidated; Infants, Toddlers and Family; and Person, Family Directed Support Waivers) are not currently a part of the Community Choice process, consumers participating in these programs are entitled to the choice of the expedited appeals process for a denial/termination of Medicaid eligibility.
The CAO is responsible for scheduling the expedited telephone appeal hearing. The hearings may be scheduled for:
Tuesdays between 9:00 a.m. and 3:00 p.m.
Thursdays between 9:00 a.m. and 3:00 p.m.
NOTE: The CAO staff does not need to be concerned if more than one expedited appeal hearing is scheduled at one time slot. The BHA will be able to accommodate more than one expedited appeal hearing at a designated time slot.
The CAO will notify the BHA site administrator of the scheduled expedited appeal hearing both via a phone call and follow-up fax.
The CAO must complete the following within two business days of the receipt of the written request for an expedited appeal:
Review the denial/termination of eligibility for Medicaid.
Contact the client (Supervisor only).
Schedule an expedited appeal hearing.
BHA will conduct the appeal and hand down a decision within 10 business days of the date the CAO receives the written request for an expedited appeal process.
CAOs that receive requests to appeal a decision of overpayments will continue to enter the appeal information into the BHA MAPPER system.
Within one business day following the BHA MAPPER update, CAOs will fax a copy of the individual’s appeal request to the Office of Inspector General (OIG) Hearings and Appeals Coordinator at (717) 772-4986.
The OIG will enter the individual’s appeal information into the OIG Avoidance and Recovery System(OARS) within one business day of receipt and if appealed timely, suspend collection activities until a fair hearing decision is rendered or the individual withdraws the appeal.
Post-hearing processing is not affected by this change.
Updated August 21, 2018, replacing September 27, 2012