130 CMR, § 610.091

Current through Register 1536, December 6, 2024

Section 610.091 - Review of Hearing Officer Decisions

(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.

(B) An order to conduct a rehearing is not to be construed, for any purpose, as indicating any position by the Medicaid director on the merits of the appeal. The Medicaid director may order such a rehearing on his or her own initiative or at the appellant's request, provided that within 14 calendar days of the date of the hearing officer's decision

(1) the Medicaid director receives the appellant's rehearing request; or

(2) the Medicaid director notifies the appellant of his or her intent to consider a rehearing.

(C) The BOH Director must send written notice, seven days in advance of the rehearing, to all parties, including the date, time, and location of such rehearing, which is held at a site reasonably convenient or agreeable to the person appealing. After the rehearing, the BOH Director may issue a superseding decision no later than 30 days after the order to conduct a rehearing. Any party to an appeal may request the BOH to treat an order to conduct a rehearing as an order to remand the appeal for further consideration by the hearing officer who rendered the original decision. The BOH allows such request only when all parties to the appeal agree.

(D) A request for a rehearing or notice of the Medicaid director's intent to consider a rehearing stays implementation or effect of the appeal decision until such request is denied or the Medicaid director otherwise decides not to order a rehearing, or the superseding rehearing decision is issued.

(E)Review of Hearing Officer Decisions Long-term Care Eligibility Decisions. The following provisions apply only to the review of the hearing officer's decisions regarding the appellant's eligibility for long-term care.

(1) If the Medicaid director does not act upon a timely request for rehearing within 45 days, the request for rehearing is deemed denied, unless the appellant advises the Medicaid director in writing before the expiration of the 45-day deadline that they do not want the request to be deemed denied if it is not acted on within 45 days.

(2) If a request for rehearing has been denied by the Medicaid director or deemed denied because the Medicaid director has not acted upon it within 45 days of the request, the appellant may immediately proceed to judicial review of the BOH's decision under M.G.L. c. 30A.

(3) Good cause for a rehearing of a hearing officer decision exists if the Medicaid director determines that the appellant has satisfactorily demonstrated that the appellant's BOH decision is directly inconsistent with a previous BOH decision or binding appellate precedent concerning the same trust language or law. To establish good cause for a rehearing to be ordered by the Medicaid director, the appellant must:

(a) attach a copy of the BOH decision the appellant is challenging;

(b) attach copies of the inconsistent prior decisions from the BOH or the appellate court or both;

(c) identify and explain the inconsistencies between the decisions and the identicality of facts and law; and

(d) provide any prior BOH decisions that are consistent with the treatment provided to appellant on the identical facts and law.

(4) Any rehearing of a long-term care eligibility decision will be confined to the specific consistency issues identified in the rehearing request. The hearing officer or the BOH Director conducting the rehearing will issue a decision that contains:

(a) a statement of the issues involved in the hearing;

(b) a summary of evidence;

(c) findings of fact on all relevant factual matters;

(d) rulings of law on all relevant legal issues, with citations to supporting regulations or other law;

(e) conclusions drawn from the findings of fact and rulings of law if appropriate; and