Abandonment

When the claimant fails without good cause, to appear (by himself or by authorized representative) at his or her scheduled hearing.

Adequate Notice

A written notice that includes:

1. A statement of what action the agency intends to take

2. The reasons for the intended agency action

3. The specific regulations supporting such action

4. An explanation of the individual's right to request a State agency hearing

5. The circumstances under which assistance is continued if a hearing is requested

6. If the agency action is upheld, that such assistance must be repaid under title IV-A, and must also be repaid under titles I, X, XIV or XVI (AABD) if the State plan provides for recovery of such payments.

Advance Notice Period

The 10 day period between the date a notice is mailed to the date a proposed action is to take effect.  (Also called Timely Notice Period.)

Adverse Benefit Determination

For recipients enrolled in a MCO, the denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit; the reduction, suspension, or termination of a previously authorized service; the denial, in whole or in part, of payment for a service; the failure to provide services in a timely manner, as defined by the State; the failure of the MCO to act within timeframes regarding the standard resolution of grievances and appeals; and the denial of a recipient's request to dispute a financial liability, including cost sharing, copayments, and other recipient financial liabilities.

Appellant

Anyone who requests a hearing.  (Also called Claimant.)

Benefits

Any kind of assistance, payments or benefits made by TANF, GA, Medicaid, Delaware Healthy Children Program (DHCP), Chronic Renal Disease Program (CRDP), Child Care, Refugee, Emergency Assistance or Food Supplement programs.

Claimant

Anyone who requests a hearing.  (Also called Appellant.)

DHSS

The Department of Health and Social Services, including:

1. The Division of Social Services (DSS), in connection with economic, medical, vocational or child care subsidy assistance

2. The Division of Medicaid and Medical Assistance (DMMA) or a managed care organization (MCO) under contract with DHSS to manage an operation of the Medicaid Program, in connection with medical assistance

3. The Division of State Service Centers (DSSC) in connection with the Emergency Assistance Program

4. The Division of Developmental Disabilities Services (DDDS) in connection with Medicaid Program services

5. The Division of Public Health in connection with Medicaid Program services

6. The Division of Services for the Aging and Adults with Physical Disabilities (DSAAPD) in connection with Medicaid Program services

DSS

The Division of Social Services (or "the Division.")

Expedited Fair Hearing

An administrative hearing for Medicaid and DHCP which provides for a decision to be issued within 3 working days from the receipt of the request for an appeal of a decision to terminate, reduce, or suspend previously authorized services or a decision to deny or limit a new service request where the standard decision time frame of 45 days could seriously jeopardize the claimant’s life or health or ability to attain, maintain, or regain maximum function.

Fair Hearing

An administrative hearing held in accordance with the principles of due process which include:

1. Timely and adequate notice

2. The right to confront and cross-examine adverse witnesses

3. The opportunity to be heard orally

4. The right to an impartial decision maker

5. The opportunity to obtain counsel, represent him or herself, or use any other person of his or her choice.

Fair Hearing Summary

A document prepared by the agency stating the factual and legal reason(s) for the action under appeal.  The purpose of the hearing summary is to state the position of the agency/entity that initiated the action in order to provide the appellant with the necessary information to prepare his or her case.

Good Cause

May include, but is not limited to the following:

1. Death in the family

2. Personal injury or illness

3. Sudden and unexpected emergencies

4. Failure to receive the hearing notice

Group Hearing

A series of individual requests for a hearing consolidated into a single group hearing. A group hearing is appropriate when the sole issue involved is one of State or federal law, regulation, or policy. The policies governing hearings will be followed In all group hearings. The individual appellant in a group hearing is permitted to present his or her case or be represented by an authorized representative.

Hearing Decision

The decision in a case appealed to the State hearing officer. The decision includes:

1. The substance of what transpired at the hearing

2. A summary of the case facts

3. Supporting evidence

4. Pertinent State or federal regulations

5. The reason for the decision

In Food Supplement Program disqualification cases, the hearing decision must also respond to reasoned arguments by the appellant.

EXAMPLE: At a Food Supplement Program Intentional Program Violation Hearing involving a failure to report a change promptly, an appellant may argue that a failure to report does not constitute "clear and convincing evidence" of intent to defraud. The hearing officer's decision must respond to this argument.

Hearing Officer

The individual responsible for conducting the hearing and issuing a final decision on issues of fact and questions of law.

Hearing Record

A verbatim transcript of all evidence and other material introduced at the hearing, the hearing decision, and all other correspondence and documents which are admitted as evidence or otherwise included for the hearing record by the hearing officer.

Hearing Summary

A document prepared by the agency stating the factual and legal reason(s) for the action under appeal. The purpose of the hearing summary is to state the position of the agency/entity that initiated the action in order to provide the appellant with the necessary information to prepare his or her case.

Hearsay Evidence

Testimony about a statement made by a third party that is offered as fact without personal knowledge

Individual Hearing

A hearing in which an individual client disagrees with the action taken by the Department on the facts of his or her case.

MCO

A Managed Care Organization under contract with DHSS to administer the delivery of medical services to recipients of Medicaid and CHIP through a network of participating providers.

Party

A party to a hearing is a person or an administrative agency or other entity who has taken part in or is concerned with an action under appeal. A party may be composed of one or more individuals.

Privilege

Appellants may decline to present testimony or evidence at a fair hearing under claim of privilege.  Privilege may include the privilege against self- incrimination or communication to an attorney, a religious advisor, a physician, etc.

Request for a Fair Hearing

Any clear expression (oral or written) by the appellant or his authorized agent that the individual wants to appeal a decision to a higher authority. Such request may be oral in the case of actions taken under the Medical Assistance or Food Supplement Program. Programs. The agency must establish procedures that permit an individual, or an authorized representative, to submit a hearing request for Medical Assistance

1. Via the internet website;

2. By telephone;

3. Via mail;

4. In person; and

5. Through other commonly available electronic means.

Relevance

Refers to evidence.  Evidence is relevant if an average person believes that the evidence makes a significant fact more probable.

Remand

To send back for further action.

Rule of Residuum

Findings of fact must be supported by at least some evidence which is admissible in a court of law.

Timely Notice Period

The 10 day period between the date a notice is mailed to the date a proposed action is to take effect.  (Also called Advance Notice Period.)

Exception: The agency must establish procedures that permit an individual, or an authorized representative, to submit a hearing request for Medical Assistance

1. Via the internet website;

2. By telephone;

3. Via mail;

4. In person; and

5. Through other commonly available electronic means.

Appellants of actions taken in the Food Supplement Program may request a fair hearing orally. If an oral request is made, inform the appellant that it is advisable to finalize the request by putting it in writing. The staff member receiving an oral request will take steps to begin the hearing process. This includes an offer, at the time of the request, to assist the appellant by putting the request in writing.