Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 332 - MAINECARE ELIGIBILITY MANUAL › Appendix 144-332-I - Preparation for and Participation in the Administrative Hearing Process

Current through 2024-29, July 17, 2024
The purpose of a hearing is to review whether the Agency
				  acted in accord with defined policy and procedural requirements in carrying out
				  its actions. The review is usually requested in relation to proposed closings,
				  denials, decreases in the level of coverage, and changes in deductible amounts.
				  The hearing may also include questions of medical eligibility, classification
				  for nursing care status and eligibility for retroactive coverage.
Hearings are not formal in the sense that there are oaths
				  given, set formal procedures of addressing individuals concerned, or required
				  procedures for entering objections or questioning at a particular time.
				  Hearings are not casual conversations or arguments, however.
In addition to reviewing the decision itself, the Hearing
				  Officer has the responsibility, at the hearing, to review whether appropriate
				  procedures were followed in carrying out the action.
The Hearing Report
The agency representative has the responsibility to be
				  prepared to give a report and to answer questions that may be asked by the
				  Hearing Officer of other participants in the hearing. The Eligibility
				  Specialist must make sure that proper written notice, with an advance notice
				  period, if applicable, was forwarded to the applicant or recipient. The notice
				  must cite the manual section on which the decision to deny or reduce benefits
				  is based. It is not sufficient to state: "You have excess assets," or "You have
				  excess income." The amount of assets or income should be given. In addition,
				  the agency limit on assets or income should be cited. It might be necessary to
				  cite more than one manual reference. If so, this should be done.
If the action results in a request for a hearing the
				  Eligibility Specialist should submit a copy of the notice which was sent to the
				  applicant or recipient to the Hearing Officer. The copy of the notice and other
				  pertinent documents will become a permanent part of the Hearing Record.
When notified of a request for a hearing, the Eligibility
				  Specialist must prepare a detailed report outlining what was done and why it
				  was done. The report should indicate how the decision was made. If income is an
				  issue, the Eligibility Specialist must elaborate on how net income was
				  determined. If assets are an issue, the Eligibility Specialist must show what
				  was considered as an asset. If medical eligibility is an issue, specifics
				  should be given as to what went into the decision that the individual no longer
				  is considered incapacitated or disabled in accord with agency policy. If the
				  decision involved the Medical Review Team, contact must be made with that unit,
				  The MRT will provide medical information if necessary.
If negative action is taken because information is
				  incomplete, inconclusive or conflicting, the Eligibility Specialist must show
				  what is inconclusive and why more information is needed. The Eligibility
				  Specialist also has responsibility to show that specific information was
				  requested and that the individual was given the opportunity to resolve
				  questions before action was taken.
A copy of the report is sent to the individual requesting the
				  hearing by the Division of Administrative Hearings prior to the hearing. If the
				  agency is informed that the individual has a representative for the hearing, a
				  copy of the report is also sent to the representative.
To the extent that the report is complete and concise, it
				  will assist the Hearing Officer in conducting the hearing and will assist the
				  applicant or recipient in understanding or questioning information.
The Hearing -
The Hearing Officer will begin the
				  hearing by giving an opening statement. In the opening statement, the Hearing
				  Officer will:
I. cite the case name and basis purpose of the
				  hearing;
II. request the names of all present;
III. remind all persons that the hearing is being recorded
				  and that individuals should follow procedures by:
A. identifying themselves and referring to each other by name
				  during the hearing;
B. make an effort to speak loud enough to be heard by all
				  participants and face the recording equipment while talking.
Note that exhibits will be presented during the
				  hearing.
After an opening statement by the Hearing Officer, the
				  Eligibility Specialist will be asked to present a copy of the notice which was
				  sent to the applicant or recipient.
The Hearing Officer will request a verbal report outlining
				  the actions taken and the basis of the action. The report submitted by the
				  Eligibility Specialist may be read or used as the basis for the verbal report.
				  The Hearing Officer may ask additional questions if there areas which are
				  unclear. In addition, copies of documents such as medical statements, budgets,
				  lists of assets or medical bills may be requested by the Hearing Officer. When
				  requested, copies of these items should be given to the Hearing Officer and the
				  individual requesting the hearing.
The individual or the representative may question the
				  decision of the Eligibility Specialist. Questions should be made through the
				  Hearing Officer and not between the persons involved.
The individual requesting the hearing will be given the
				  opportunity to:
I. question any information;
II. refute any information;
III. present any additional information or make any
				  comments.
In situations where additional information is presented, the
				  Hearing Officer will decide whether the information had a bearing on the
				  decision in question at the time of the decision or whether the information
				  relates to a period of time subsequent to the decision. If the latter is the
				  situation, the information should only be considered in a re-application or in
				  carrying out a subsequent review.
After both parties have presented information and entered any
				  questions and the Hearing Officer is satisfied that pertinent data has been
				  presented, the Officer will summarize the issue as much as possible.
A continuance of the hearing may be determined by the Hearing
				  Officer if additional date is needed, obtainable, and not available at the
				  hearing. If the applicant or recipient requests a continuance, the Hearing
				  Officer will determine if it would be appropriate.
The agency representative should always have manual material
				  at the hearing and be prepared to cite necessary data from the manual.
Appeal
When the above procedures are followed and there is further
				  appeal through the courts, those persons responsible for representing the
				  agency have issues that are clearly defined. In addition, procedures such as
				  adequate and specific notice may be raised in court even if not mentioned at a
				  hearing. Thus, it is necessary that procedures taken, as well as the decision
				  made, be reviewed at the hearing.