Issue Alert - 11-04-01

The State Office of Administrative Hearings (SOAHR), which conducts hearings for DHS, has issued revised “Instructions to DHS ALEs within MAHS” with “Guidance on handling cases in which Medical Assistance Based on Disability and/or State Disability Assistance (MA-P/SDA) is at issue”. 

Under the instructions, MAHS clarifies that applicants and recipients are permitted to introduce certain medical evidence of their disability at the hearing.  However, Administrative Law Judges (ALJs) are not permitted to order additional medical tests or examinations unless they “relate to the impairment/disability alleged on the application for disability benefits or in the medical documentation submitted to the Department prior to the final eligibility determination” or to impairments that “relate to or have any effect on” the impairments alleged on the application or shown in the medical records reviewed by MRT.

Thus, it appears a client who has an undisclosed cognitive impairment and applies for Medicaid based on severe, uncontrolled diabetes and hypertension could not submit evidence of the cognitive impairment at the hearing unless it was written up in the medical records reviewed by MRT or can be recognized as “related to or having an effect on the diabetes and hypertension” (for example, resulting in compromised ability to adhere to a medication and diet regime)  However, it appears that client could submit new evidence of heart disease related to the diabetes or hypertension.

Thus, in some cases the new policy denies the claimant the right to an evidentiary hearing and transforms the hearing into a review on the record rather than a de novo hearing. 

By refusing to allow claimants to introduce some evidence of disability, the policy denies them their right to a full evidentiary hearing under state and federal law, as summarized in the Background, above.

In addition, the new policy will deny prompt Medicaid coverage to individuals who are eligible for Medicaid but are barred from establishing their eligibility at a hearing, in violation of federal law.  42 U.S.C. 1396a(a)(8).  It also may result in denial of retroactive coverage to eligible individuals, in violation of 42 U.S.C. 1396a(a)(34).  Individuals who are eligible for Medicaid but are denied by MRT based on insufficient medical documentation will be forced to re-apply for Medicaid in order for DHS to consider additional medical documentation.  This inevitably will result in delays in accessing Medicaid and loss of Medicaid for some or all months of retroactive eligibility.

Finally, the new policy will violate the maintenance of eligibility requirements of the American Recovery and Reinvestment Act (ARRA) and the Affordable Care Act (ACA), which prohibit the state from imposing new standards, methodologies, or procedures for determining eligibility for Medicaid that are more restrictive than the standards, methodologies, or procedures that were in effect on July 1, 2008 (for ARRA) and March 23, 2010 (for the Affordable Care Act). See section 1501 of ARRA (Pub. L. 111-15) and 42 U.S.C. 1396a(gg)(1).  The new procedures are more restrictive because some applicants will be denied eligibility under these procedures who would have been determined eligible under the old procedures.