§ 7.5 Medicaid Hearings and Appeals

• Library: Elder Law (OSBar) (2017 Ed.)

§ 7.5 MEDICAID HEARINGS AND APPEALS

§ 7.5-1 Generally

A Medicaid applicant or recipient whose benefits have been adversely affected by a DHS decision is generally entitled to a contested-case hearing under the Oregon Administrative Procedures Act. See ORS 183.413-183.471; OAR 461-025-0300 to 461-025-0375. The contested case is conducted by an administrative law judge (ALJ) from the Office of Administrative Hearings (OAH). ORS 183.630. The OAH has 65 independent, professional ALJs on its panel. See ORS chapter 183 for Oregon's Administrative Procedures Act.

§ 7.5-2 Notice

DHS must notify an applicant or a recipient in writing of a proposed action that will affect the person's request for or receipt of Medicaid assistance. The "decision notice" (see OAR 461-001-0000(20)) must:

(1) Specify the date on which the notice is mailed;

(2) Specify the action that the agency plans to take and the effective date of the action;

(3) Specify the reasons for the action and the rules that support the action;

(4) Describe the person's hearing rights;

(5) Specify the method and deadline for requesting a hearing;

(6) Inform the person of "the right to representation, including legal counsel, and the right to have witnesses testify on his or her behalf"; and

(7) Provide information about the "availability of free legal help."

OAR 461-175-0010(1).

See ORS 183.415(2) (notice, hearing, and record in contested cases); OAR 137-003-0001 (contested-case notice).

A decision notice is required whenever the agency approves or denies an initial application, or plans to close or reduce the client's benefits. OAR 461-175-0200. The agency will also send a decision notice in the following long-term care situations:

(1) Notice to both spouses of the amounts of the CSRA and CSIA (see § 7.3-4(d) regarding the CSRA and § 7.3-4(b) regarding the CSIA);

(2) Notice to terminate benefits if a client receiving community-based care or long-term care services has not paid the required amount of his or her income toward the cost of services; and

(3) Denial or termination notice due to a disqualifying transfer of resources.

OAR 461-175-0225 (CSRA and CSIA); OAR 461-175-0230(3)(a) (client liability); OAR 461-175-0310 (resource-transfer disqualification).

§ 7.5-3 Request for Hearing

A client who receives an adverse decision notice may request a hearing. A client may also request a hearing if DHS fails to make a decision on a request for Medicaid within 45 days of the application. OAR 461-025-0310.

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