Article 18 Section 1 State Hearings

 

Table of Contents

Title

MPG Cite

State Hearings

18.01.01

Aid Paid Pending Procedures

18.01.02

Conditional Withdrawal / Out of Hearing Resolution

18.01.03

Abandonment of the Claim and Withdrawal

18.01.04

State Hearings Held

18.01.05

State Hearing Decisions

18.01.06

 


18.01.01 State Hearings

 

A.
General

A State Fair Hearing (aka: an administrative hearing) is a quasi-judicial process conducted by an administrative law judge (ALJ), whereby an applicant/recipient of public assistance (aka: claimant) exercises his/her right to obtain a full and impartial review of a County or State action.  State Hearings regarding Medi-Cal actions are governed by the State Manual of Policy and Procedures (MPP), Section 22-000 and Medi-Cal Eligibility Manual (MEM) Article 18.

 

In accordance with Title 22, Section 50591, the California Department of Social Services (CDSS) – State Hearing Division (SHD) Sacramento is responsible for the overall administration of the hearing process which includes:

·   Receiving requests for hearings

·   Scheduling the hearings

·   Notifying the County and individual of the hearing schedule

·   Providing Administrative Law Judges (ALJ)

 

Once a request for a hearing has been filed with the State, the process continues until the hearing has been held and adjudicated, or the claimant withdraws or abandons his/her hearing request.
 
MPG LTR 712 (11/10)

MPP

22-000

 

B.
Disputes and Complaints

Whenever possible, disputes and complaints are to be handled within the FRC at the lowest level beginning with the worker.  Every effort should be made to answer all questions, clarify any confusion and resolve any issue(s) on a case. The applicant/recipient should be informed of their right to appeal while the issues are being resolved.  When the dispute or complaints cannot be resolved at initial contact, the worker will continue their efforts to resolve at lowest level.   When attempts to resolve issues informally by a worker or supervisor are unsuccessful, the worker has the following responsibilities:

 

Step

Action

1

Inform the individual of their right to a hearing.

2

Assist the individual, when requested, in filing a hearing request.

3

Advise the individual of the proper procedures for filing a hearing as outlined below.

 

MPG LTR 712 (11/10)

 

C.
Filing a State Hearing

The worker will not discourage the individual from seeking a State Hearing even when the action taken by worker appears correct. 

 

There are two ways to file for a hearing:

Written Request

·   Complete the “Request for State Hearing” NABACK9 on the back of the Notice of Action (NOA), or

·   Submit request in any written form.

 

Individual may submit the written request in one of these ways:
Mail or deliver request

State Hearings

Appeals Section

4990 Viewridge Ave - MS W402

San Diego, CA 92123-1661
Mail Request

California Dept of Social Services

State Hearings Division

P.O. Box 944243

Mail Station 19-37

Sacramento, CA 94244-2430

Fax
State Hearing Division at fax 1-916-229-4110

Oral Request

·   Toll free by telephone to CDSS, PIAR at

-   1-800-952-5253 (Voice).

-   1-800-952-8349 (TDD).

 

NOTE:  The State Hearing Division cannot accept requests via e-mail.  If a hearing request is received by the FRC or ACCESS, the worker must date stamp the request, narrate in CalWIN Case Comments, fax the request to Appeals immediately at 858-514-6826, and forward the original via County Mail to Appeals at Mail Stop W402.

 

MPG LTR 712 (11/10)

 

D.
Worker Required Actions

Upon notification from Appeals that a hearing request has been filed, the worker will:

Step

Action

1

Review case to determine if the action disputed by the claimant is in accordance with regulations.

2

If case actions are found to be incorrect, take corrective action immediately, rescind case action and send claimant appropriate NOA.

3

Notify Appeal Representative of case findings.

4

Document case actions in case comments.

 

NOTE: A case in receipt of Aid Paid Pending does not prevent the worker from taking corrective actions that benefit the client or taking action on newly reported information that would require a new NOA.

 

MPG LTR 712 (11/10)

MPP

22.073.2

 

E.
Time Constraints
 

The State is required to provide to both the County and the claimant a minimum of ten days advance notice of the scheduled hearing date, time and location.  The Appeals Representative must make the Position Statement available to the claimant and/or AR at least 2 workings days prior to the hearing.  When the Appeals Section is notified that a hearing has been filed, the claimant’s name is cleared.  The Appeals clerk prepares individual lists for each FRC Appeals Liaison of these cases which require immediate review and appropriate action by the worker.

 

Because of the time constraints imposed by law, it is imperative that all activities relating to State Hearings be given immediate attention.  The State will not postpone a hearing simply because the County may need more time to prepare its position.

 

MPG LTR 712 (11/10)

MPP

22-073. 252

 

F.
Case Status

Family Resource Center is responsible for State Hearings dispositions and will follow specific instructions issued by Appeals Representative to correct case actions, within the timelines established.

 

If the case is ...

Then the ...

active,

current case-carrying FRC is responsible for activities required in connection with State Hearings regardless of when/where the issue requiring attention originated.

closed, and activity to open the case is necessary,

FRC to which the case was last assigned will be responsible.

closed, and the activity needed is calculation of an overpayment,

case will be referred to Overpayment Specialist Unit (OSU).

                        

MPG LTR 712 (11/10)

 

18.01.02 Aid Paid Pending Procedures (APP)

 

A.
Introduction

When an individual files a timely request for a hearing on a NOA proposing to increase the SOC or reduce, discontinue, or terminate aid, he/she as a general rule is entitled to APP. The responsibility for the initial determination regarding APP rests solely with the Appeals Section.  Also, if the NOA was not timely and/or adequate, the claimant is entitled to APP even if the hearing request was not filed timely.  APP shall not be initiated nor discontinued without instructions from the Appeals Section.  When aid is to be paid pending the hearing, the Appeals Representative will issue specific instruction to the APP Group at Fraud and Integrity regarding case actions to be coordinated with the CalWIN Help Desk and the MEDS Coordinator in Automation.  All telephone instructions from the Appeals Section to the worker will be confirmed in writing via email.

 

MPG LTR 712 (11/10)

 

B.
Appeals Section
Actions

The Appeal Section has the following responsibility:

·   Review of the case and applicable State regulations and County procedures and assist the individual in the appeal process.

·   Presentation of the County’s position during the hearing and ensuring compliance with State hearing decisions.

·   Notify State Hearing Division if an interpreter may be necessary or was requested by the claimant.

·   Inform claimant of their rights under the appeals process including the right to:

-   Receive adequate and timely notice,

-   Legal representation,

-   Present evidence and/or witnesses in support of their position,

-   Cross examine County witnesses, and

-   Ask pertinent questions of the Appeal Representative regarding the

   County’s position.

 

The Appeals Representative will send a notice alerting the FRC Appeals Liaison of a pending State Hearing.  If APP is ordered, benefits will continue unchanged only as it pertains to those actions under Appeal.  Normal case process continues and workers must take action on any new reported information that would require a new NOA.

 

When APP is ordered, the ALJ may review and make a ruling at the hearing at the request of the Appeals Representative as to whether APP should continue pending the final decision on the case.   If the Appeals Representative has not ordered APP, the AJL may reverse that decision at the hearing at the request of the claimant and order APP issued. 

 

MPG LTR 712 (11/10)

MPP

22-073.

211

 

C.
Worker Required Actions

The APP Group at Fraud and Integrity and CalWIN Help Desk must promptly issue the aid in accordance with the APP instructions, following procedures outlined in the EEOG.  APP is to be issued within five working days of the receipt of the hearing request by the County.

 

1

Medi-Cal benefits will continue unchanged only as it pertains to those issues covered by the appeal. 

2

New issues not covered by an appeal can still result in termination of benefits, increase, or decrease in the SOC, and require a new NOA.

 

Once the appeal process has started, the FRC will:

 

1

Remain in communication with the Appeals Section regarding any further case actions that affect the issue(s) under appeal.

2

Provide clarifying information when requested for the investigation and preparation of the State Hearing.

3

Communicate with the claimant or his/her AR to correct inadvertent errors, obtain information and resolve eligibility questions.

 

The Appeals Section will be the first point of contact for resolution of any APP issuance problems.

 

NOTE:  When the claimant designates an AR for a state hearing, the worker will only discuss matters pertaining to the state hearing with the AR.  

 

MPG LTR 712 (11/10)

 


18.01.03 Conditional Withdrawal / Out of Hearing Resolution

 

A.
Introduction

A claimant may choose to conditionally withdraw his/her request for a state hearing pending resolution of identified case action(s) mutually agreed upon.  A Conditional Withdrawal (CWD) is a 30-day agreement between the County and the claimant.  The conditions of the withdrawal specify the action(s) to be taken by the worker and/or claimant.  The Appeal Representative prepares the conditional withdrawal for the claimant or AR to sign.

 

The Out-of-Hearing Resolution (OHR) form 03-13 HHSA is used to communicate instructions to the worker.  The form will explain why the case action(s) is being modified, the action(s) required and the regulations and/or policies involved.  

 

The FRC Appeals Liaison will be notified weekly via e-mail with a list of cases resolved with an OHR.  The list indicates the OHR has been imaged by Appeals into DoReS where the worker will review for immediate action.

 

MPG LTR 712 (11/10)

MPP

22-073.231

 

B.
Appeals Section
Actions

The Appeals Section will resolve the issue(s) under appeal without a hearing whenever possible.  When the Appeals Representative determines that the County action cannot be upheld in a hearing, an OHR shall be issued and imaged into DoReS.

 

The Appeals Representative will issue the OHR via email to the FRC Appeals liaison with instructions to the worker outlining the action(s) to be taken.  The OHR will outline:

 

1

The issue(s),

2

The action(s) required for compliance,

3

Why the action(s) cannot be supported at hearing, and

4

The supporting State and County regulations and policies.

 

MPG LTR 712 (11/10)

 

 

 

 

 

 

 

MPP

22-073.

231(a)

 

C.
Worker
Required Actions

The worker will take immediate action to comply with the OHR. The FRC will notify Appeals when the OHR is completed. 

 

If the worker is unable to comply by the due date indicated on the OHR, the worker must contact the Appeals Representative prior to the due date to request an extension.  The worker will document in case comments all efforts made to comply and reasons why extension is requested.

 

MPG LTR 712 (11/10)

 

D.
Disagreement with Out of Hearing Resolution

When the worker disagrees with the directed action, the following procedures must be followed:

 

Step

Action

1

The worker will have five working days in which to resolve the disagreement, with day one to begin the work day following the receipt of the OHR notice.  These five days are included in the 30 days that the worker has to complete the OHR.

2

The worker will review the case with their supervisor to ensure consensus. 

3

When the worker has new information or believes the OHR is incorrect the FRC Appeal Liaison will contact Appeals Representative to discuss and resolve.

4

When the FRC Appeal Liaison wishes to request a formal review of the Appeals action, the FRC Manager may request a review.  Within the original five workings days, the FRC Manager will contact the Appeals Section Manager.

5

When the decision is not reversed by Appeals, the action to comply with the OHR must be completed within the original 30 day timeline.

6

When the decision is reversed by Appeals, the Appeal Representative will contact the claimant or AR to explain the circumstances of the reversal and inquire if the claimant wishes to re-open their hearing request with the State. Reversal of the OHR is contingent upon the client’s agreement, when the claimant or AR agrees with the reversal the Appeals Representative will issue a new OHR.

 

MPG LTR 712 (11/10)

 


18.01.04 Abandonment of the Claim and Withdrawal

 

A.
Abandonment of Claim

When the claimant requests a state hearing, they are considered to have a claim regarding their case.  When they or their AR fail to appear for the hearing or are present but unwilling to proceed, they are considered to have abandoned that claim.   A written decision regarding the dismissal will be issued to the claimant and their AR.

 

Upon a showing of good cause, the claimant or his/her AR may request to set aside the dismissal decision within 15 days of the issued decisions.  If the decision is set aside and a new hearing scheduled. APP benefits must be reinstated on those cases in which APP benefits had been originally approved.

 

MPG LTR 712 (11/10)

 

 

 

 

 

 

MPP

22-054.

222

 

B.
Withdrawal

When an appealed action has been rescinded, resolved to the claimant’s satisfaction or when the claimant changes his/her mind about the appeal, the claimant may withdraw (WD) the request for the hearing. The Appeals Representative will prepare and provide a withdrawal form for the claimant or his/her AR to sign. 

 

MPG LTR 7 (3/88)

 

C.
Worker Required Actions

If the claimant abandons or withdrawals their claim, the Appeals Representative notifies the FRC Appeal Liaison via email.  The email will instruct the worker to stop APP if previously ordered, and whether APP received is an overpayment of benefits.  If the dismissal decision is set aside upon order of the State Hearing Division, the APP must be reinstated. 

 

The worker will take immediate action within five working days to stop the APP. 

 

MPG LTR 712 (11/10)

MPP

22-071.1

 


18.01.05 State Hearings Held

 

A.
Workers
Required Actions
 

When the Appeals Representative determines that an action can be upheld, the Appeals Representative prepares the case for hearing.  If the Appeals Representative determines the worker’s testimony is needed at the hearing, the Appeals Representative will notify the FRC Appeals Liaison and FRC Manager vie e-mail requesting the worker’s presence at the hearing, indicating the date, time, and place of the hearing.

 

When the worker believes that other workers were involved in the specific case action and are, therefore, better qualified to testify at the hearing, the worker will immediately notify his/her supervisor and the Appeals Representative. 

 

The claimant or his/her authorized representative can serve a formal subpoena to a worker.

 

Workers will not act as the authorized representative or a witness for an individual at a hearing, as this is considered a conflict of interest.  

 

MPG LTR 712 (11/10)

 


18.01.06 State Hearing Decisions

 

A.
Decisions
 

The County receives written verification of each hearing decision.  A claimant’s request for hearing is considered that individual’s claim against the County. 

 

State hearing decisions are not precedent setting and the decision relates only to the issues raised in conjunction with that specific case.  A hearing decision may result in the following:

 

Part

Function

Grant the claim

Rule in favor of the individual

Deny the claim

Rule in favor of the County

Grant in part and deny in part

Rule in favor in part for the individual and in part for the County, with both grant and deny outcomes

Dismiss the claim

Rule there is no jurisdiction or that the claimant abandoned their hearing request.

 

MPG LTR 7 (3/88

 

 

 

 

 

 

ACWDL

94-35

 

B.
Claims Denied or Dismissed

If the claimant is denied or dismissed, the Appeals Representative emails a copy of the decision to the FRC Appeal Liaison. The email will instruct the worker to stop APP if previously ordered.

 

Note: APP in Medi-Cal cases as a general rule is not an overpayment.

 

The worker will take immediate action within five working days to stop the APP. 

 

MPG LTR 712 (11/10)

 

C.
Claims Granted or Granted in Part

The County must submit a compliance report to the State on each case where a claim is fully or partially granted.  The Appeals Representative will send the FRC Appeal Liaison the following documents:

 

Form

Function

DSS 03-1 Appeals Compliance Instruction Letter

Instructs worker what actions are to be taken to comply with the State’s decision and the due date.

DSS DPA 27 Report of County Compliance With State Hearing Decisions

Confirms that the worker has complied with the State’s hearing decision.  It must be submitted to the State by Appeals within 30 days from the date the decision is received in Appeals section.

 

When any part of the claimant’s claim is granted, the worker will review the decision immediately to ensure that instructions are clear and that the deadline can be met.  Any issue with meeting the due date on the Compliance Instruction Letter must be reported to the Appeals Representative immediately as the County may incur financial sanctions for late compliance.

 

MPG LTR 712 (11/10)

 

D.
Timelines

The Appeals Representative will notify the FRC of all State Hearings decisions by emailing the DSS 03-1 Appeals Compliance Instruction Letter to the FRC Appeal liaison.  Compliance timelines for completion of all case activities are listed below:

 

Step

Action

1

Appeals Representative emails the FRC Appeal liaison the DSS 03-1.

2

FRC Appeal liaison reviews the DSS 03-1 and assigns to worker within 1 working day.

3

Worker takes corrective case action within 10 days of receipt of hearing decision by the FRC. 

4

Worker notifies Appeal Representative of completed case actions.

5

 

If the…

Then the…

corrective case actions are not completed,

Appeals Representative will email FRC Appeal liaison on the 11th day.

FRC Appeal liaison does not respond within 24 hours,

Appeals Representative will elevate to FRC manager via email.

 

MPG LTR 712 (11/10)

 

E.
DSS DPA 27 Form Completion

The completed DSS DPA 27 is the documentation used by the State to monitor proper and timely compliance with hearing decisions.  The claimant is notified by the State that the County has reported compliance with the hearing decision.  The DSS DPA 27 is not to be completed until all required actions have actually been taken, including issuances of an adequate NOA. 

 

Once all case actions are completed, the worker will complete the DSS DPA 27 with the following information:

 

Step

Action

1

·   Date the form is completed,

·   Date when all of the actions ordered by the decision have been completed,

·   Specify the action taken, the effective dates and/or period covered by each action,

·   Name and worker number of the person completing the compliance report,

·   Telephone number where the contact person can be reached,

2

Attach all supporting documents as requested by the Appeals Representative and return the DDS DPA 27 to the Appeals Section.

 

MPG LTR 712 (11/10)