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Administrative Hearing decision
Revised Date:
July 25, 2014
Purpose: To clarify the different types of orders and decisions that may be issued during an administrative hearing on eligibility for Apple Health programs.
Worker Responsibilities
When a decision is received, document in the ACES narrative with the docket number, the type of decision, and the date of mailing. Include any other information necessary, including the outcome of the hearing process.
- Reversed decisions: When the agency's decision is reversed, immediately:
- Review the decision to determine if a request for reconsideration is needed. If so:
- Document in ACES the reason for the request for reconsideration;
- Send the request to OAH with a copy to the appellant.
- If no request for reconsideration is needed:
- Reopen or approve coverage back to the date the action took place;
- Document the actions and decision; and
- Send a letter to the household advising them of the hearing outcome and action taken to approve coverage.
- Review the decision to determine if a request for reconsideration is needed. If so:
- Affirmed decisions: When the agency's decision is affirmed, immediately :
- Terminate continued coverage. Adequate notice must be provided to the appellant, but advance notice is not required.
- Review the period of continued coverage, and establish overpayments as appropriate.
- Document in ACES the decision.
- Petition for review of initial decision:
- After implementing the initial decision, determine if a review is appropriate:
- Consult with a supervisor, administrator, or program manager, as appropriate
- Consult with training or program management staff (i.e., Office of Medicare, Medicaid Eligibility and Policy), if necessary
- If the decision is made to petition for a review of the initial decision, prepare a memorandum for Board of Appeals. Include:
- Appellant's name and docket number,
- All areas in which the agency believes the ALJ erred. See chapter 182-526 WAC for the review standard. The review judge usually only addresses areas that have been raised in the petition. Refer to findings of fact and conclusions of law by the number assigned in the decision;
- Cite WACs, findings of fact, or evidence in the record that support the agency's argument;
- New evidence which affects the decision and was not available for the initial hearing (even after reasonable diligence) can be brought up in the review, and
- A request for the review judge to find in the agency's favor.
- Ensure the review is sent to Board of Appeals and all other parties within the stated deadlines.
- After implementing the initial decision, determine if a review is appropriate:
- Appellant petition for review:
- Do not reinstate continued coverage pending a review of the initial decision requested by the appellant.
- Review the appellant's petition to determine an appropriate response.
- If a response is required, prepare a memorandum to the Board of Appeals and include:
- The appellant's name and the docket number,
- A response which speaks only to the issues raised by the appellant, and
- Argument which supports the finding in the initial decision.
- Ensure the response is sent to Board of Appeals and all other parties within the stated deadlines.
- Receipt of review decision:
- Implement the review decision immediately.
- See chapter 182-526 WAC to determine if a request for reconsideration is appropriate.
- If a reconsideration is appropriate, prepare a memorandum to the Board of Appeals including the specific reason why the department does not agree with the review decision.