Opinion ID: 4707402
Heading Depth: 3
Heading Rank: 2

Heading: Fair Hearing Appeal Rights

Text: Bellin argues in the alternative that Medicaid beneficiaries are entitled to an appeal of initial care hours determinations based on the guarantee of fair hearing appeal rights in 42 U.S.C. § 1396a(a)(3) and accompanying CMS regulations. State Medicaid plans must “provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness.” 42 U.S.C. § 1396a(a)(3). This requirement is further outlined by CMS regulation: The State agency must grant an opportunity for a hearing to . . . [a]ny individual who requests it because he or she believes the agency has taken an action erroneously, denied his or her claim for eligibility or for covered benefits or services, or issued a determination of an individual’s liability, or has not acted upon the claim with reasonable promptness . . . . 42 C.F.R. § 431.220(a)(1). Bellin argues that RiverSpring “denied . . . her claim for . . . covered . . . services” and she was entitled to appeal that denial at a fair hearing. Id. But Bellin did not make a “claim” for personal care services that was “denied.” Id. As explained in Part III.A above, Bellin did not and could not request a certain number of hours when she sought evaluation by RiverSpring. Bellin points to statements by CMS that the denial of a claim includes the “denial of a particular ‘level of benefits,’” Appellant’s Br. 20, but this does not alter the analysis. No party disputes that, once enrolled, recipients may request additional personal care services hours and may appeal the denial of their request. What Bellin fails to provide support for is the proposition that potential recipients at any point make a “claim” for a particular Id. at 27,507. This same misreading underlies the use of “potential enrollee” on the next page of the Federal Register, which Bellin also cites in support of her argument. See id. at 27,508. 35 number of hours of personal care services that is denied through MLTCs’ initial hours determinations. In the absence of clear textual support for her view, Bellin argues that interpreting federal law not to require a fair hearing right in the instant circumstance would “amount to an improper repeal of the long-standing appeal rights granted by 42 U.S.C.[]§ 1396a(a)(3).” Appellant’s Br. 34. In making this argument, Bellin relies on the well-established presumption that Congress does not repeal earlier statutes sub silentio. See Nat’l Ass’n of Home Builders v. Defs. of Wildlife, 551 U.S. 644, 662 (2007) (“We will not infer a statutory repeal unless the later statute expressly contradicts the original act or unless such a construction is absolutely necessary in order that the words of the later statute shall have any meaning at all.”). According to Bellin, an interpretation of § 1396u-2 that denies beneficiaries fair hearing rights effects a repeal of § 1396a and should be avoided. In the fee-for-service model, local social services districts determine beneficiaries’ entitlement to personal care services and the number of hours they receive. These determinations are subject to appeal in a fair hearing. Congress passed § 1396u-2 in 1997 and substantially expanded states’ ability to use a managed care model to deliver Medicaid services. See Balanced Budget Act of 1997, Pub. L. No. 105-33, 111 Stat. 251. New York now requires beneficiaries like Bellin to receive personal care services from MLTCs. These managed care organizations both assess beneficiaries’ care hours needs and provide them with that care. Bellin would have us read into § 1396u-2 a congressional guarantee that beneficiaries’ fair hearing rights remain untouched in the move to managed care. We see no basis in the statute to understand that Congress intended such a guarantee. For example, § 1396u-2 requires managed care organizations to set up internal appeal procedures. See 42 U.S.C. § 1396u-2(b)(4) (requiring managed care organizations to 36 “establish an internal grievance procedure under which an enrollee . . . may challenge the denial of coverage of or payment for such assistance”). Although not addressed in the statute, subsequently issued CMS regulations require that beneficiaries’ appeals be handled by managed care organizations in the first instance; only after that can beneficiaries demand an appeal through a fair hearing. See 42 C.F.R. § 438.408(f)(1) (“An enrollee may request a State fair hearing only after receiving notice that the [managed care organization] . . . is upholding the adverse benefit determination.”); see also id. § 438.402(b) (“Each [managed care organization] . . . may have only one level of appeal for enrollees.”). The result is a substantial limitation of beneficiaries’ rights to appeal through a fair hearing. Bellin cites statements by CMS during a notice and comment period regarding 42 C.F.R. Part 438 to argue that “CMS has explicitly disavowed any intent to limit individual[s’] pre-existing appeal rights under 42 U.S.C. § 1396a(a)(3).” Appellant’s Br. 36. Upon closer inspection, however, CMS did no more than largely reiterate the importance of beneficiaries generally retaining fair hearing rights. For instance, Bellin cites a CMS statement that it was “critical that all beneficiaries . . . have access to the State fair hearing process rights provided for” in § 1396a(a)(3). Medicaid Program; Medicaid Managed Care, 66 Fed. Reg. 6228, 6341 (Jan. 19, 2001). But no party disputes that beneficiaries remained entitled to robust fair hearing rights under the managed care model. The question is whether those fair hearing rights had to mirror prior feefor-service hearing rights in every respect. In promulgating the internal grievance procedure rules, CMS explained that it was acting pursuant to its authority under § 1396a(a)(3) as well as § 1396u-2, and that before its rulemaking, § 1396a(a)(3)’s fair hearing requirements “ha[d] not been implemented in regulations that appl[ied] to managed care enrollees.” Id. at 6335. CMS thus recognized that a managed care model required the development of new fair hearing procedures tailored to that model. 37 Accepting Bellin’s argument would demand that we import wholesale the fair hearing requirements applicable to the fee-for-service model into this substantially different context. Finding Bellin’s reading of the statutory language strained, we decline to do so. Bellin is not wrong that New York’s managed care system has altered beneficiaries’ appeal rights. If every MLTC that evaluates a beneficiary makes too low an initial personal care services hours determination, that beneficiary is left with no choice but to accept one of the offers of care, begin care receiving fewer hours than she is entitled to receive, and then go through the process of requesting more hours, waiting for a decision, appealing internally, and appealing to a fair hearing. Meanwhile, the State does not dispute that the same beneficiary in a fee-for-service care delivery model would be entitled to appeal immediately the number of personal care hours initially determined. The limits on beneficiaries’ appeal rights may prove important on remand in evaluating Bellin’s procedural due process claims. They do not provide a persuasive basis for concluding that beneficiaries have a federal statutory right to appeal an MLTC’s initial care hours determination.