reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.035 - Dismissal of a Request for a Hearing

Current through Register 1525, July 5, 2024
(A) BOH
			 will dismiss a request for a hearing when
(1)
			 the request is not received within the time frame specified in
			 130 CMR
			 610.015;
(2) the request is withdrawn by the
			 appellant;
(3) the sole issue is
			 one of state or federal law requiring automatic change in assistance for
			 classes of members;
(4) the stated
			 reason for the request does not constitute grounds for appeal as set forth in
			 130 CMR
			 610.032. Without limiting the generality of
			 the foregoing, except as provided in
			 130 CMR
			 610.032(A)(11), no provider
			 decision or action including, but not limited to, a provider determination
			 about whether or the extent to which a service is medically necessary,
			 constitutes an appealable action hereunder;
(5) the stated reason for the hearing request
			 is outside the scope of
			 130 CMR 610.000 as set
			 forth in
			 130 CMR 610.003;
(6) BOH has conducted a hearing and issued a
			 decision on the same appealable action arising out of the same facts that
			 constitute the basis of the request;
(7) the party requesting the hearing is not
			 an applicant, member, or resident as defined in
			 130 CMR
			 610.004;
(8) BOH learns of an adjustment or action
			 that resolves all of the issues in dispute between the parties;
(9) BOH learns that the applicant or member
			 has passed away before or after the date of filing and there is no full
			 compliance with
			 130 CMR 610.016(B)
			  within ten days of a BOH request;
(10) BOH learns that the applicant or member
			 has passed away prior to the date of filing and scheduling of the hearing and
			 is not informed until the date of the hearing and there is no full compliance
			 with
			 130 CMR
			 610.016(B); or
(11) the appellant fails to appear at a
			 scheduled hearing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.036 - Continuation of Benefits Pending Appeal

Current through Register 1525, July 5, 2024
(A)
			 When the appealable action involves the reduction, suspension, termination, or
			 restriction of assistance, such assistance will be continued until BOH decides
			 the appeal or, where applicable, the rehearing decision is rendered if BOH
			 receives the initial request for the fair hearing before the implementation
			 date of the appealable action. If such appealable action was implemented before
			 a timely request for a hearing, such assistance will be reinstated if BOH
			 receives the request for the fair hearing within ten days of the mailing of the
			 notice of the appealable action. If the hearing officer's decision is adverse
			 to the appellant, the appealable action will be implemented immediately, except
			 as provided in
			 130 CMR
			 610.091(D).
(B) When a change affecting the member's
			 assistance occurs while the hearing decision is pending, the MassHealth agency
			 will take appropriate action to implement the subsequent change affecting
			 assistance, subject to the advance notice requirements and the right to
			 assistance pending a hearing decision.
(C) Assistance pending a hearing will not be
			 granted if the MassHealth agency has granted assistance on a presumption of
			 eligibility and subsequently determines that the member is ineligible, and such
			 determination is the subject of a hearing request.
(D) Assistance continued pending an appeal in
			 accordance with 130 CMR 610.036(A) is subject to recoupment.
(E) The provisions of 130 CMR 610.036(A) and
			 (B), regarding assistance pending a hearing decision, will not apply to
			 assistance requiring prior authorization where such assistance terminates as
			 the result of the expiration of the specified, finite authorization period, and
			 the member's provider has failed to timely submit a new prior authorization
			 request.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.037 - Notice Requirements for PASRR Determinations

Current through Register 1525, July 5, 2024
(A) When DMH or DDS issues a PASRR
			 determination, it must provide written notice of the PASRR determination to the
			 following:
(1) the evaluated individual and
			 his or her legal representative;
(2) the admitting or retaining nursing
			 facility;
(3) the attending
			 physician; and
(4) the discharging
			 hospital, if the individual is seeking nursing facility admission from a
			 hospital.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.046 - Notification of Hearing

Current through Register 1525, July 5, 2024
(A) The time, date,
			 and place of the hearing will be arranged so that the hearing is accessible to
			 the appellant. Advance written notice will be mailed by BOH to all parties
			 involved at least ten days prior to the hearing date in order to permit
			 adequate preparation of the case. However, the appellant may request less
			 advance notice to expedite the scheduling of the hearing.
(B) The notice will contain the following:
(1) the date, time, and location of the
			 hearing;
(2) the address and
			 telephone number for BOH to allow for notification if a party cannot attend the
			 scheduled hearing and needs to submit a request for rescheduling in accordance
			 with
			 130 CMR
			 610.048;
(3) an explanation of the MassHealth agency's
			 hearing procedures, including the appellant's right to representation at the
			 appellant's expense;
(4) a
			 statement that the appellant or appeal representative may examine the case file
			 (or resident record, as applicable) before the hearing; and
(5) a statement to the appellant indicating
			 that the MassHealth agency will dismiss the hearing request if the appellant or
			 his or her appeal representative fails to appear for the hearing without good
			 cause.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.047 - Scheduling

Current through Register 1525, July 5, 2024
(A) Upon receipt of a request for a fair
			 hearing, BOH will register the appeal, set a date for a hearing and so notify
(1) the appellant and any appeal
			 representative or authorized representative;
(2) the appropriate office of the MassHealth
			 agency and the managed care contractor or nursing facility; and
(3) if applicable, the MassHealth agency
			 employee against whom allegations of coercive or otherwise improper conduct
			 have been made.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.048 - Procedures and Requirements for Rescheduling

Current through Register 1525, July 5, 2024
(A)
Rescheduling before the Day of the Hearing
.
(1) BOH may change the date, time, and
			 location of the hearing upon due notice to the parties involved.
(2) For good cause shown as defined in 130
			 CMR 610.048(D), BOH may, at the request of any party to a hearing, reschedule
			 the hearing provided that the request is received before the date of the
			 hearing. If the BOH Director or his or her designee concludes that the request
			 does not constitute good cause, the request will be denied.
(3) If a party does not request to reschedule
			 or is denied a request to reschedule and fails to attend the hearing, the
			 appeal will be dismissed.
(4) BOH
			 will inform the parties of the procedures set forth in 130 CMR 610.048(A)(1)
			 through (3).
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.049 - Dismissal for Failure to Prosecute

Current through Register 1525, July 5, 2024
When the record discloses the failure of the appellant to file
				documents required by
				130 CMR 610.000, to respond
				to notices or correspondence, or to comply with orders, or when the appellant
				otherwise indicates an intention not to continue with the prosecution of his or
				her appeal, BOH may issue an order requiring the appellant to show cause why
				the matter should not be dismissed for lack of prosecution. The BOH Director
				will make the show cause determination; however, in cases where the hearing has
				been scheduled and a hearing officer has been designated to conduct the
				hearing, the hearing officer will make the determination. If the appellant is
				found to have failed to show such cause, the appeal will be dismissed with
				prejudice.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.050 - Right to Examine Case File and Documents, or "Discovery"

Current through Register 1525, July 5, 2024
(A)
Appeals of MassHealth
			 Determinations
. The appellant will have reasonable opportunity to
			 examine the entire contents of the appellant's case file, as well as all
			 documents and records to be used by the MassHealth agency at the hearing. An
			 appointment must be scheduled in advance with the appropriate MassHealth
			 Enrollment Center (MEC) or MassHealth agency unit for examination of the case
			 file.
(B)
Appeals of
			 PASRR Determinations
. The appellant will have reasonable
			 opportunity to examine the appellant's PASRR evaluation, including all
			 documents and records used in performing the evaluation, as well as all
			 documents and records to be used at the hearing by the department that issued
			 the PASRR determination. An appointment to examine the documents must be
			 scheduled in advance with the department that issued the PASRR
			 determination.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.051 - Adjustment Procedures and Mediation

Current through Register 1525, July 5, 2024
(A)
MassHealth Agency
. The MassHealth agency is primarily
			 responsible for dealing with complaints from applicants or members.
			 Dissatisfaction on the part of applicants or members may result from a lack of
			 knowledge or understanding of the regulations that govern MassHealth policies
			 and procedures. Ordinarily, complaints may be resolved with an explanation of
			 the regulations by the representative. If the MassHealth representative's
			 explanation is not satisfactory, the representative's immediate supervisor will
			 be available to respond to the complaint. If the complaint cannot be resolved,
			 the MassHealth agency will remind the applicant or member of the right to
			 request a fair hearing.
(B)
Adjustments Resolving Issues
. The MassHealth agency or
			 the acting entity may make an adjustment in the matters at issue before or
			 during an appeal period. If the parties' adjustment resolves one or more of the
			 issues in dispute in favor of the appellant, the hearing officer, by written
			 order, may dismiss the appeal in accordance with
			 130 CMR
			 610.035 as to all resolved issues, noting as
			 the reason for such dismissal that the parties have reached agreement in favor
			 of the appellant. BOH will not delay a fair hearing because a possible
			 adjustment is under consideration, unless the appellant requests or agrees to
			 such a delay.
(C)
Mediation
. BOH may offer to the parties the
			 opportunity to resolve one or more of the appeal issues in dispute through
			 mediation, and such mediation may proceed only if, and as long as, both parties
			 agree to such mediation that will be conducted substantially in accordance with
			 M.G.L. c. 233, § 23C. If such mediation resolves one or more of the issues
			 in dispute, the hearing officer, by written order, will dismiss the appeal, as
			 to all resolved issues, noting as the reason for such dismissal that the
			 parties have reached agreement. Either party may elect to terminate mediation
			 at any time and proceed to a fair hearing that BOH will schedule accordingly.
			 Any party may request that a different hearing officer be assigned to conduct
			 such fair hearing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.052 - Subpoenas

Current through Register 1525, July 5, 2024
(A) A subpoena under
			 130 CMR 610.000 is a
			 document that commands a witness to appear at a given time to give testimony at
			 an administrative proceeding. A subpoena can also require the witness to
			 produce for the administrative proceeding any books, documents, papers, or
			 records in his or her possession or control.
(B)
Right to
			 Subpoena
. Any party to a hearing and BOH on its own have the right
			 to request a subpoena requiring the attendance, testimony of witnesses, and the
			 production of any evidence including books, records, correspondence, or
			 documents relating to any matter in question at the hearing. Any party may
			 submit to BOH a written request for the issuance of such subpoena. If, in its
			 discretion and in accordance with
			 130 CMR
			 610.065(B), BOH allows such
			 request, a subpoena will be issued within three business days of receipt of
			 such request.
(C)
Petition to Vacate Subpoena
. Any witness subpoenaed
			 may petition BOH to vacate or modify a subpoena.
(1) BOH gives the party who requested the
			 issuance of the subpoena notice of such petition orally or in writing. The
			 notice must contain the contents of the petition and indicates that the party
			 may oppose the petition orally or, if time permits, in writing to BOH. If time
			 does not permit a party to respond to the request to vacate, the hearing will
			 be postponed long enough to permit the party to respond to the petition. This
			 procedure is not be construed to require a hearing or adjudicatory
			 proceeding.
(2) After such
			 investigation as BOH considers appropriate, BOH may grant the petition in whole
			 or in part upon a finding that:
(a) the
			 testimony or the evidence whose production is required does not relate with
			 reasonable directness to any matter in question;
(b) the subpoena is unreasonable or unduly
			 burdensome; or
(c) the subpoena has
			 not been issued in a reasonable period in advance of the time when the evidence
			 to be produced is requested.
(3) Unless BOH finds that at least one of the
			 conditions in 130 CMR 610.052(C)(2)(a) through (c) exists, BOH will deny the
			 petition.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.061 - Appellant Rights

Current through Register 1525, July 5, 2024
The appellant must have the right to
(A) be assisted by an appeal representative
			 of his or her choice as provided in
			 130 CMR
			 610.016;
(B) present witnesses;
(C) examine and introduce evidence from his
			 or her case file or resident record, if applicable, and examine and introduce
			 any other pertinent documents of the MassHealth agency or other
			 party;
(D) present and establish
			 all relevant facts and circumstances by oral testimony and documentary
			 evidence;
(E) advance any pertinent
			 arguments without undue interference; and
(F) question or refute any testimony, and
			 confront and cross-examine adverse witnesses.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.062 - Acting Entity Rights and Responsibilities

Current through Register 1525, July 5, 2024
The acting entity will
(A) submit to the hearing officer, at or
			 before the hearing, all evidence on which any action at issue is
			 based;
(B) designate a staff person
			 or representative to appear at the hearing, and arrange for adequate space for
			 the hearing if requested by BOH;
(C) have the right to present
			 witnesses;
(D) where the acting
			 entity is the MassHealth agency, ensure that the case file is present at the
			 hearing and that the appellant has adequate opportunity to examine it before
			 and during the hearing;
(E) where
			 the acting entity is a nursing facility, ensure that the relevant portions of
			 an appellant's resident record are present at the hearing and that the
			 appellant has adequate opportunity to examine such records before and during
			 the hearing upon reasonable request;
(F) where the acting entity is DDS or DMH and
			 the appellant is appealing his or her PASRR determination, ensure that all
			 medical records comprising the PASRR evaluation are present at the hearing and
			 that the appellant or the appellant's representative has adequate opportunity
			 to examine them before and during the hearing;
(G) introduce into evidence material from
			 pertinent documents that pertain to the issue or issues raised during the
			 hearing and that are not otherwise confidential;
(H) present and establish all relevant facts
			 and circumstances by oral testimony and documentary evidence;
(I) have the right to advance any pertinent
			 arguments without undue interference;
(J) have the right to question and refute any
			 testimony and confront and cross-examine adverse witnesses;
(K) have the right to arrange for the
			 appearance at the hearing of a representative of other assistance programs,
			 where appropriate; and
(L) where
			 the acting entity is a managed care contractor, ensure that the relevant
			 paperwork is present at the hearing and that the appellant has adequate
			 opportunity to examine it before and during the hearing.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.064 - MassHealth Agency Employee Rights

Current through Register 1525, July 5, 2024
Any MassHealth agency employee against whom allegations of
				coercive or otherwise improper conduct have been made may present his or her
				own case and will have the right to
(A) be assisted by a representative of his or
			 her choice at his or her own expense;
(B) bring witnesses or subpoena witnesses
			 upon request to BOH;
(C) present
			 and establish all relevant facts and circumstances by oral testimony and
			 documentary evidence;
(D) advance
			 any pertinent arguments without undue interference;
(E) question or refute any testimony and
			 confront and cross-examine adverse witnesses; and
(F) examine and introduce any pertinent
			 evidence, including material from the case file.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.065 - Powers and Duties of the Hearing Officer

Current through Register 1525, July 5, 2024
(A)
			 The hearing officer has the following duties:
(1) to administer the oath or affirmation to
			 anyone who will testify at the hearing and to an
			 interpreter/translator;
(2) to
			 assist all those present in making a full and free statement of the facts in
			 order to elicit all the information necessary to decide the issues involved and
			 to ascertain the rights of the parties;
(3) to ensure an orderly presentation of the
			 evidence;
(4) to ensure that all
			 parties have a full opportunity to present their claims orally or in writing
			 and to secure witnesses and evidence to establish their claims;
(5) to receive, rule on, exclude, or limit
			 evidence;
(6) to ensure a record is
			 made of the proceedings;
(7) to
			 render a fair, independent, and impartial decision based on the issues and
			 evidence presented at the hearing and in accordance with the law, including the
			 MassHealth agency's rules, regulations, and
Policy Memoranda
,
			 and to order MassHealth agency action if appropriate; and
(8) to inform appellants who are not fluent
			 in English of the right to a full and accurate interpretation by their own
			 interpreter, or by a MassHealth agency-provided interpreter. The hearing
			 officer will conduct the bilingual hearing in accordance with the guidelines
			 for conducting hearings through interpretation in the Hearing Officer Manual.
			 The purpose of the guidelines is to enable non-English speaking appellants to
			 understand and to participate in the entire hearing as fully as if the
			 appellants were fluent in English. To achieve this end, all statements,
			 including questions, answers, and comments, of the appellant, hearing officer,
			 witnesses, and any other persons participating in the hearing, will be fully
			 translated without alteration of such statements, such as by changing from the
			 first person to the third person.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.071 - Evidence

Current through Register 1525, July 5, 2024
(A)
General
.
(1) The rules of evidence observed by courts
			 do not apply to fair hearings, but the hearing officer observes the rules of
			 privilege recognized by law. Evidence may be admitted and given probative
			 effect only if it is the kind of evidence on which reasonable persons are
			 accustomed to rely in the conduct of serious affairs. Unduly repetitious or
			 clearly irrelevant evidence may be excluded.
(2) The hearing officer may not exclude
			 evidence at the hearing for the reason that it had not been previously
			 submitted to the acting entity, provided that the hearing officer may permit
			 the acting entity representative reasonable time to respond to newly submitted
			 evidence. The effective date of any adjustments to the appellant's eligibility
			 status is the date on which all eligibility conditions were met, regardless of
			 when the supporting evidence was submitted.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.072 - Continuance

Current through Register 1525, July 5, 2024
Once a hearing has been opened, it may be continued at the
				discretion of the hearing officer. All parties will be notified as to the time,
				date, and location of the continued hearing in accordance with
				130 CMR
				610.081.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.073 - Consolidated Hearings

Current through Register 1525, July 5, 2024
(A) BOH may respond
			 to a series of individual requests for hearings by conducting a single group
			 hearing. BOH may consolidate cases when
(1)
			 the applicable state or federal law is common to all such cases; and
(2) the issues of fact are undisputed, or are
			 common to all such cases.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.074 - The Record

Current through Register 1525, July 5, 2024
(A) All documents
			 and other evidence offered and taken become part of the record. The record
			 further contains electronic or stenographic recordings of the proceedings or
			 transcripts of such recordings, if produced, and all exhibits and documents
			 introduced at the hearing and, wherever applicable, medical documents obtained
			 to resolve medical issues. The record is the exclusive source of facts for the
			 hearing officer's decision. For purposes of judicial review, the record
			 includes the decision, but does not include recordings or transcripts of the
			 proceedings, unless requested by the appellant. If the appellant requests a
			 recording or transcript, the appellant bears the cost of producing such
			 recording or transcript, unless such cost is waived by the MassHealth agency or
			 the court.
(B) All evidence and
			 testimony at the hearing are recorded either electronically by the hearing
			 officer or stenographically.
(C) At
			 the discretion of the hearing officer, any party may record the hearing, so
			 long as the request to record is made to the hearing officer and the other
			 party before the recording commences.
(D) Regardless of whether an appellant
			 intends to file a complaint for judicial review, transcripts or duplicate tapes
			 of the proceedings are supplied, upon request by the appellant, at his or her
			 expense. The record is open for inspection by any party during the regular
			 business hours of BOH. To review the record, an appointment must be made with
			 BOH in advance. Requests for appointments shall be addressed as expeditiously
			 as possible.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.081 - Reopening before Decision

Current through Register 1525, July 5, 2024
After the close of the hearing and before a decision, the
				hearing officer may reopen the record or, if appropriate, the hearing if he or
				she finds need to consider further testimony, evidence, materials or legal
				rules before rendering his or her decision. If the hearing officer decides to
				reopen the record, he or she must notify all parties accordingly and all
				parties will have the opportunity to submit such additional testimony,
				evidence, materials, or legal argument as the hearing officer may describe in
				such notice and within such time period that the hearing officer may so
				establish, unless the party waives the right at hearing to receive a copy of
				and respond to such submission. All such additional submissions must be sent to
				the other party or parties who will have the opportunity to respond to such
				submissions within such time period as the hearing officer may establish. If
				the hearing officer decides to reopen the hearing in the form of a continuance
				according to
				130 CMR 610.071, he or
				she must send written notice, at least seven days in advance of the resumed
				hearing, to all parties of the reopening. Such written notice must include the
				date, time, and location of the resumed hearing and must be held at a location
				accessible to the appellant. Before a hearing decision is rendered, any party
				to a hearing may request in writing that the hearing officer exercise his or
				her power hereunder, and such request will become part of the
				record.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.082 - Basis of Fair Hearing Decisions

Current through Register 1525, July 5, 2024
(A) The
			 hearing officer's decision is based upon evidence, testimony, materials, and
			 legal rules, presented at the hearing, including the MassHealth agency's
			 interpretation of its rules, policies, and regulations. Any evidence,
			 testimony, materials, legal rules, or arguments presented after the close of
			 the hearing will be excluded, unless the record or hearing is reopened by the
			 hearing officer pursuant to
			 130 CMR
			 610.081, or the parties stipulate procedures
			 for response, or the parties otherwise waive the right to respond.
(B) The decision must be based upon a
			 preponderance of evidence.
(C) The
			 decision must be rendered in accordance with the law.
(1) The law includes the state and federal
			 constitutions, statutes, and duly promulgated regulations, as well as decisions
			 of the state and federal courts.
(2) Notwithstanding 130 CMR 610.082(C)(1),
			 the hearing officer must not render a decision regarding the legality of
			 federal or state law including, but not limited to, the MassHealth regulations.
			 If the legality of such law or regulations is raised by the appellant, the
			 hearing officer must render a decision based on the applicable law or
			 regulation as interpreted by the MassHealth agency. Such decision must include
			 a statement that the hearing officer cannot rule on the legality of such law or
			 regulation and must be subject to judicial review in accordance with
			 130 CMR
			 610.092.
(3) The hearing officer must give due
			 consideration to
Policy Memoranda
and any other MassHealth
			 agency representations and materials containing legal rules, standards,
			 policies, procedures, or interpretations as a source of guidance in applying a
			 law or regulation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.083 - Content of Decision

Current through Register 1525, July 5, 2024
(A) Unless subject
			 to 130 CMR 610.083(C), the hearing decision will contain the following:
(1) statement of the issues involved in the
			 hearing;
(2) summary of
			 evidence;
(3) findings of fact on
			 all relevant factual matters;
(4)
			 rulings of law on all relevant legal issues, with citations to supporting
			 regulations or other law;
(5)
			 conclusions drawn from the findings of fact and rulings of law if appropriate;
			 and
(6) the hearing officer's order
			 for appropriate action.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.084 - Transmittal of Decision

Current through Register 1525, July 5, 2024
Unless waived, copies of the decision will be forwarded to the
				appellant, the appellant's appeal representative, the appellant's interpreter
				(if requested), and representatives of the acting entity, as applicable. The
				appellant, his or her appeal representative and, for appeals held pursuant to
				130 CMR
				610.032(C), the nursing
				facility will also be notified in writing of the right of judicial
				review.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.085 - Finality of the Appeal Decision

Current through Register 1525, July 5, 2024
(A) Except
			 as otherwise provided under 130 CMR 610.085(B), 610.085(C), and
			 610.091,
			 the following will apply.
(1) The decision of
			 the hearing officer will be final and binding on the acting entity.
(2) The acting entity will not interfere with
			 the independence of the fact-finding process of the hearing officer. Facts
			 found and issues decided by the hearing officer in each case are binding on the
			 parties to that case and cannot be disputed again between them in any other
			 administrative proceeding nor used as binding precedent by other parties in
			 other proceedings.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.086 - Implementation of the Appeal Decision

Current through Register 1525, July 5, 2024
(A)
Decisions When the MassHealth Agency Is the Acting
			 Entity
.
(1)
Notification to Appellant
. When the decision is
			 issued, BOH must notify the appellant of his or her right to full and prompt
			 implementation of the decision within 30 days, except as provided under
			 130 CMR
			 610.091. The notice directs the appellant to
			 notify the appropriate BOH official in writing if there is not full compliance
			 within 30 days.
(2)
Responsibility of the MassHealth Agency
. The
			 MassHealth agency is responsible for the full and prompt implementation of all
			 fair hearing decisions so that the appellant will receive any benefits due
			 within 30 days of the date of the decision, except as provided under
			 130 CMR
			 610.091. No official or any other employee of
			 the MassHealth agency may obstruct the implementation of the fair hearing
			 decision, except as provided under
			 130 CMR
			 610.091.
(3)
Procedure for Monitoring
			 Implementation
. The MassHealth agency monitors approved and denied
			 appeal decisions to ensure implementation and compliance within 30 days of the
			 decision, except as provided under
			 130
			 CMR 610.091.
(4)
Expedited Appeals for Denied
			 Acute Hospital Admission
. When a member requests an expedited
			 appeal of a denial of prior authorization for an elective hospital admission,
			 pursuant to
			 130
			 CMR 610.015(E), the
			 MassHealth agency will comply with the decision of the hearing officer as soon
			 as possible, but no later than seven days from the date of the decision, except
			 as provided under
			 130
			 CMR 610.091. The hearing officer's decision
			 pertaining to such appeal establishes whether the MassHealth agency will
			 approve the admission and, if applicable, determines the length of stay.
			 However, the hearing officer's decision does not establish whether medical care
			 provided following the admission is medically necessary.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.091 - Review of Hearing Officer Decisions

Current through Register 1525, July 5, 2024
(A)
			 The Medicaid director (but not his or her designee) may, for good cause shown,
			 send an order for the BOH Director to conduct a rehearing of an appeal. Good
			 cause is defined in regard to the rehearing of long-term care eligibility
			 decisions at
			 130
			 CMR 610.091(E)(3). The BOH
			 Director (but not his or her designee) conducts the rehearing, except the BOH
			 Director may appoint another hearing officer to conduct the rehearing if the
			 BOH Director:
(1) is unable to conduct the
			 rehearing due to a conflict of interest;
(2) was the hearing officer at the original
			 hearing for which the rehearing is requested; or
(3) is ill or unavailable and an extended
			 delay would be prejudicial to any of the parties.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.092 - Judicial Review

Current through Register 1525, July 5, 2024
(A) If the
			 appellant is dissatisfied with the final decision of the hearing officer, he or
			 she may exercise the further right of judicial review in accordance with M.G.L.
			 c. 30A. The right to such judicial review is also available to a nursing
			 facility regarding a final decision in a hearing instituted under
			 130
			 CMR 610.032(C).
(B) A party seeking judicial review must file
			 a complaint with the Superior Court in the county where that party lives or has
			 its principal place of business, or in Suffolk County, within 30 days after
			 receipt of the fair hearing decision.
(C) If the appellant timely requests a
			 rehearing or remand, in accordance with
			 130
			 CMR 610.091, then the decision following the
			 rehearing or remand, or the denial of the request for the rehearing or remand,
			 is the MassHealth agency's final action and the appellant has 30 days from the
			 final action to file a complaint for judicial review.
(D) The MassHealth agency must notify the
			 appellant and his or her appeal representative of the appellant's right to seek
			 judicial review and of the time limits for seeking such review.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.093 - Access to the Record

Current through Register 1525, July 5, 2024
The record of the fair hearing is provided to the appellant
				within the appropriate time limits after filing a complaint for judicial
				review. BOH provides access to the record of the hearing in accordance with
				130
				CMR 610.074. Such access may be accomplished
				by allowing the appellant to examine all the documentary evidence and to listen
				to the recording, or to review the hearing with the stenographer, if applicable
				and appropriate.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.401 - Introduction

Current through Register 1525, July 5, 2024
130 CMR 630.000 governs the
				provision of services under the Acquired Brain Injury Home-and Community-based
				Services waivers (ABI Waivers) and the Moving Forward Plan Home-and
				Community-based Services waivers (MFP Waivers). All providers of services under
				these Home- and Community-based Services (HCBS) waivers must comply with
				MassHealth regulations set forth in
				130 CMR 630.000 and
				130 CMR 450.000:
Administrative and Billing Regulations
, and with HCBS
				regulations and requirements established by the Centers for Medicare and
				Medicaid Services.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.403 - Eligible Members

Current through Register 1525, July 5, 2024
(A) MassHealth pays
			 for services under an HCBS waiver only when provided to eligible MassHealth
			 members who are enrolled as participants in the HCBS waiver, in accordance with
			 130 CMR
			 519.007(G):
Home-
			 and Community-based Services Waivers for Persons with Acquired Brain
			 Injury
and (H):
Money Follows the Person Home- and
			 Community-based Services Waivers
, subject to the restrictions and
			 limitations described in
			 130 CMR 630.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
			 130 CMR
			 630.405 specifically states, for each HCBS
			 waiver, which HCBS waiver services are covered and which HCBS waiver
			 participants are eligible to receive those services.
(B) For information on verifying member
			 eligibility and coverage type,
see
130 CMR
			 450.107:
Eligible Members and the
			 MassHealth Card
.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.404 - Provider Eligibility

Current through Register 1525, July 5, 2024
(A)
Requirements for Participation
. An individual or
			 organization seeking to participate as a provider of services under an HCBS
			 waiver must
(1) be duly authorized to conduct
			 a business in Massachusetts that delivers health or human services to elderly
			 or disabled adult populations;
(2)
			 comply with all standards, requirements, policies, and procedures established
			 by DDS or MRC for the provision of services under an HCBS waiver;
(3) meet the applicable HCBS waiver service
			 provider application qualifications;
(4) comply with all standards, requirements,
			 policies, and procedures established by the MassHealth agency for the
			 participation of providers in MassHealth, including all provider participation
			 requirements described in
			 130 CMR 630.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
;
(5) obtain, as required, a MassHealth
			 provider number; and
(6) accept
			 MassHealth payment, DDS payment, or MRC payment where applicable, as payment in
			 full for all services provided under an HCBS waiver.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.405 - HCBS Waiver Coverage Types

Current through Register 1525, July 5, 2024
A participant is eligible for HCBS waiver services according to
				the applicable HCBS waiver under which the participant is enrolled.
See
130 CMR
				519.007:
Individuals Who Would Be
				Institutionalized
. Each HCBS waiver coverage type is described in 130
				CMR 630.405(A) through (D). Payment for the covered services listed in
				130 CMR 630.000 is subject
				to all conditions and restrictions of MassHealth, including all applicable
				prerequisites for payment.
(A)
Acquired Brain Injury with Residential Rehabilitation (ABI-RH)
			 Waiver
. The following ABI waiver services are covered for
			 eligible MassHealth members who are enrolled as participants under the ABI-RH
			 Waiver:
(1) residential
			 habilitation;
(2) assisted living
			 services;
(3) shared living - 24
			 hour supports;
(4) supported
			 employment;
(5) community-based day
			 supports;
(6) day
			 services;
(7) occupational
			 therapy;
(8) physical
			 therapy;
(9) specialized medical
			 equipment;
(10) speech
			 therapy;
(11) transitional
			 assistance; and
(12)
			 transportation.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.406 - HCBS Waiver Conditions for Payment

Current through Register 1525, July 5, 2024
(A) The
			 MassHealth agency pays an HCBS waiver provider for the provision of waiver
			 services in accordance with the applicable payment methodology and rate
			 schedule established by EOHHS.
(B)
			 Payment for services is subject to the conditions, exclusions, and limitations
			 set forth in
			 130 CMR 630.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
.
(C) The MassHealth agency pays an HCBS waiver
			 provider for a waiver service only if
(1) the
			 member was enrolled as a participant under one of the HCBS waivers on the date
			 of service;
(2) the service billed
			 was appropriate and necessary;
(3)
			 the service billed was authorized and included in the service plan for the
			 participant pursuant to
			 130
			 CMR 630.409(A);
(4) the waiver services were provided by an
			 HCBS waiver provider in accordance with the requirements of
			 130 CMR 630.000 and
			 130 CMR 450.000:
Administrative and Billing Regulations
; and
(5) the service is provided with the use of
			 EVV as required by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.407 - HCBS Waiver Coverage Requirements

Current through Register 1525, July 5, 2024
(A)
Limitations on Covered Services
. The MassHealth
			 agency pays for HCBS waiver services provided to a participant who resides in a
			 home- or community-based setting, which may include, without limitation, a
			 temporary residence. With the exception of respite services, as described in
			 130 CMR 630.427,
			 and transitional assistance, as described in
			 130 CMR
			 630.435, the MassHealth agency does not pay
			 for HCBS waiver services provided to a participant who is a resident or
			 inpatient of a hospital, nursing facility, Intermediate Care Facility for
			 Individuals with Intellectual Disability (ICF/IID), or any other medical
			 facility subject to state licensure or certification.
(B)
Least Costly Form of
			 Care
. The MassHealth agency pays for HCBS waiver services only
			 when services are the least costly form of comparable care available in the
			 community.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.408 - Nonpayable Services

Current through Register 1525, July 5, 2024
(A) The MassHealth
			 agency does not pay for any HCBS waiver services that are furnished before the
			 development of the service plan or that are not included in a participant's
			 service plan pursuant to
			 130
			 CMR 630.409(A).
(B) The MassHealth agency does not pay for
			 HCBS waiver services that are provided to any individual other than the
			 participant who is eligible to receive such services and for whom such services
			 are approved in the service plan.
(C) The MassHealth agency does not pay an
			 HCBS waiver provider for
(1) any service that
			 is not listed as a covered service for the participant under
			 130 CMR
			 630.405;
(2) any service that is not authorized in the
			 service plan;
(3) any service to a
			 person who is a resident or inpatient of a hospital, nursing facility, ICF/IID,
			 or any other medical facility subject to state licensure or certification,
			 except for respite services, in accordance with
			 130 CMR 630.427,
			 and transitional assistance, in accordance with
			 130 CMR
			 630.435;
(4) any service to a participant who is
			 receiving a service from another home- and community-based waiver
			 program;
(5) the cost of room and
			 board, unless provided as part of respite care in accordance with
			 130 CMR
			 630.427;
(6) the cost of maintenance, upkeep, an
			 improvement, or home accessibility adaptations to a residential habilitation
			 site, group home, or other provider-owned and -operated residential
			 setting;
(7) the cost of
			 maintenance, upkeep, or an improvement to a participant's place of residence,
			 except for home accessibility adaptations in accordance with
			 130 CMR 630.417,
			 and transitional assistance in accordance with
			 130 CMR
			 630.435; and
(8) any service that is provided without the
			 use of EVV as required by the MassHealth agency.
Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 630.000 - Home- and Community-Based Services Waiver services › Section 630.409 - Service Plan and Notice of Approval or Denial of HCBS Waiver Services

Current through Register 1525, July 5, 2024
(A)
Service Plan
.
(1) The MassHealth agency or its designee
			 assigns a case manager to each participant under an HCBS waiver.
(2) The participant will lead the service
			 plan process where possible. The participant's representative should have a
			 participatory role, as needed and as defined by the participant, unless the
			 legal representative has decision-making authority.
(3) The service planning process must comply
			 with requirements in the federally approved HCBS waiver application and HCBS
			 waiver policies for service planning established by DDS or MRC, and must
			 include identification of the strengths, preferences, and cultural
			 considerations of the participant, goals, desired outcomes, clinical and
			 support needs, HCBS services and supports to be furnished, strategies for
			 solving disagreement within the process, and modifications that are supported
			 by a specific assessed need and justified in the service plan.
(4) The service plan must also comply with
			 all requirements in the federally approved HCBS waiver application and HCBS
			 waiver policies for service plans established by DDS or MRC including, but not
			 limited to, containing the HCBS services and supports to be furnished, the
			 amount, frequency, and duration of each service, and the type of provider to
			 furnish each service; reflecting that the setting in which the participant
			 resides was chosen by the participant; reflecting clinical and support needs as
			 identified through an assessment of functional needs; reflecting risk factors
			 and measures in place to minimize them; and documenting that any additional
			 conditions are supported by a specific assessed need and justified in the
			 service plan.
(5) The service plan
			 may not be backdated.