Virginia Administrative Code › Title 12 - HEALTH › Agency 30 - DEPARTMENT OF MEDICAL ASSISTANCE SERVICES › Chapter 110 - ELIGIBILITY AND APPEALS › Part I - Client Appeals › Subpart II - Hearing Officer Review › Article 3 - Hearing › Section 12VAC30-110-220 - Evidentiary hearings

Current through Register Vol. 40, No. 24, July 15, 2024
A.
						General. The hearing officer shall review all agency determinations that are
						properly appealed; conduct informal, fact-gathering hearings; evaluate evidence
						presented; and issue a written final decision that is based on the evidence,
						policy, laws, and regulations relevant to the appeal.
B. De novo hearing. All hearings shall be
						considered "de novo," meaning that the department's hearing officer will
						consider all relevant evidence submitted during the appeal in order to make a
						determination on the issues on appeal, even if the evidence was not previously
						received by the agency. The hearing officer shall consider testimony and
						evidence that explains, supports, or is probative to the issues on appeal. In
						the de novo hearing, no deference is given to the agency or contractor who took
						the action.
C. Burden of proof. The
						burden of proof shall be assigned to the party that is attempting to make a
						change. If an individual is seeking initial Medicaid eligibility, the initial
						approval of Medicaid covered services, or eligibility for a higher level of
						coverage than has already been approved, the individual has the burden of
						proof. Conversely, when an already-eligible individual is facing a proposed
						termination or reduction in Medicaid eligibility or medical services, the
						burden of proof shall be assigned to the entity that has proposed the change to
						an individual's coverage. To prevail in the appeal, the party with the assigned
						burden of proof shall establish its position by a preponderance of the
						evidence.
D. Submission of
						evidence. The appellant's appeal request should include all documents the
						appellant would like considered during the appeal. The appellant can also
						submit additional documents leading up to and during the appeal hearing. The
						hearing officer has the discretion to reschedule or delay a hearing in order to
						allow the hearing officer and agency time to review documents submitted close
						to or at the scheduled hearing. Post-hearing supplementation of the record is
						addressed in
						12VAC30-110-360. If the appeal
						request does not identify the action being appealed with reasonable
						specificity, include documentation to validate authorization for
						representation, if elected, or the department requests good cause for late
						filing of the appeal, then delay will be added to the appeal decision due date
						per 42 CFR
						431.244.
E. Previously approved coverage. In an appeal
						involving a proposed termination or reduction of previously approved coverage,
						the existence of the prior approval shall create a presumption that the
						approval was proper when it was previously made if it was consecutive to the
						current request. The strength of this presumption is directly related to the
						number and duration of previous approvals. For the entity that has proposed the
						termination or reduction to satisfy its burden of proof, it must demonstrate
						that the individual's circumstances have changed or that the previous approval
						was made in error.
Statutory Authority: §
														32.1-325 of the Code of
							 Virginia; 42 USC §
															1396 et
							 seq.