1701 Eligibility Appeals

Policy

A customer has the right to ask for an appeal when an adverse action is taken on the customer’s Medical Assistance (MA) application or benefits.  This request must be made within 35 calendar days of the date the letter is sent (see MA1702).  The customer may also ask for an appeal when a decision is not made about the customer’s MA application within the required timeframe (see MA1301B – Timeframes).

A customer has the right to ask for an expedited appeal. A request for an expedited appeal will be approved only when the request is supported by a statement from a medical provider who is recommending a procedure or treatment for the individual. The medical provider statement must say that:

The customer has a procedure or treatment scheduled, or the individual is unable to schedule a procedure or treatment due to the lack of coverage;

The customer does not currently have  health insurance that will cover most of the cost of a treatment; and

The customer’s life, physical or mental health, or ability to reach, keep, or regain full functionality will be put at serious risk if the customer has to delay a procedure or treatment for 90 days or less from the date of the appeal request.

Expedited appeals must be resolved as soon as possible and no later than seven working days after receipt.

Exceptions:

Customers are not entitled to an appeal when the adverse action is due to a change in Federal or State law.  Actions that do not affect the customer’s services, benefits or costs are not entitled to an appeal.  The customer may file a grievance for such actions (see MA1710).

There are two state agencies in Arizona that determine eligibility for AHCCCS MA programs: AHCCCS and the Department of Economic Security (DES).  Generally the agency that makes the eligibility decision processes any appeal request on that decision.  However, both agencies work together to coordinate the appeal process when a person asks for an appeal and decisions were made by both agencies.  Representatives from both agencies may need to attend the hearing depending on the program decision being appealed.

See the following table for more details on which agency determines each MA program:

NOTE          People who are eligible for SSI-Cash, Title IV-E Foster Care or Adoption Subsidy are automatically eligible for MA.  A separate MA determination is not done except when the customer is applying for ALTCS. 

Definitions

Agency Responsibilities

The agencies’ general responsibilities include:

·        Taking requests for appeals;

·        Contacting the customer if a request for an appeal is made by someone other than a customer or representative;

·        Sending any necessary authorization and notification forms to the customer;

·        Determining whether a hearing may be granted;

·        Coordinating the pre-hearing discussion (see MA1703);

·        Scheduling the hearing and notifying the customer; and

·        Preparing a hearing packet.

The Office of Administrative Hearings (OAH) or Office of Appeals (OOA) is responsible for the following:

·        Setting the hearing date and notifying the customer and the agency Fair Hearing Coordinator;

·        Appointing an Administrative Law Judge (ALJ) to conduct the hearing; and

·        Providing an interpreter and reasonable accommodations, upon request.

The ALJ is responsible for the following:

·        Presiding over the eligibility hearing;

·        Basing a decision solely on evidence presented at the hearing; and

·        Issuing a written decision.

Customer Rights and Responsibilities

The customer has the right to:

·        Review and get a copy of any part of the case file needed to present the case that is not protected by law from being released;

·        Review all documents the State agency will use at the hearing;

·        Bring legal counsel, a relative, friend, other spokesperson or witness to the hearing;

NOTE      Except for legal counsel, anyone representing the customer or serving as a spokesperson or witness for the customer cannot be a paid representative or anyone else being paid to attend the hearing.

·        Present all related facts and circumstances;

·        Present an argument without unnecessary interference;

·        Question or contradict any testimony or evidence.  This includes an opportunity to confront or cross-examine witnesses;

·        Ask the agency to furnish an interpreter; and

·        Ask the agency to make an accommodation for special needs.

Legal Authority

This requirement applies to the following programs: