A recent order of the Office of Administrative Hearings (John P. Dean, Administrative Law Judge) signifies strong support for the due process rights of DC Medicaid beneficiaries.
BR, a Salazar class member and DC Medicaid beneficiary, filed for a fair hearing after her managed care organization (MCO), Health Services for Children with Special Needs, Inc. (HSCSN), stopped payment to her therapy provider, effectively terminating her prescribed services. Although HSCSN refused to pay for any visits occurring in October 2012 or later, the provider was only notified of that fact in January 2013. The beneficiary received a copy of the letter denying payment sent to the provider. In February 2013, the beneficiary filed for a fair hearing because her services had been terminated without notice, requesting that her services continue pending the resolution of the hearing.
HSCSN resisted this request, claiming that the beneficiary’s claim for continued services pending the resolution of the hearing was barred, because she filed the request more than ten days after she received notice of the action in a letter to the provider denying payment. The Department of Health Care Finance (DHCF) filed a paper supporting the position of the Medicaid beneficiary that benefits pending the resolution of the fair hearing were appropriate.
Although the ALJ agreed with HSCSN that the beneficiary had requested the continued services more than ten days after she received the denial letter, because that denial letter was addressed to, and intended for, the provider, and only discussed the provider’s rights in relation to the decision, the ALJ held that the beneficiary had never received notice within the meaning of the Medicaid statutes and regulations, and so the ten-day deadline had never begun to run, entitling the beneficiary to benefits pending the resolution of the hearing. The ALJ held that, under the DC Public Assistance Act, no deadline regarding administrative hearings may start to run until the beneficiary receives clear notice of the deadline and of how to file the hearing request. To see the decision, use this link.