Notice
Medicaid applicants and recipients are entitled to notice of any action affecting their claims or benefits. Community spouses of Medicaid applicants or recipients are also entitled to notice of any action affecting their community spouse resource or income allowances. If the Illinois Department of Human Services proposes to reduce, suspend, or terminate assistance, the notice must be at least ten days in advance of the proposed action (except in certain narrow circumstances, such as when the agency has factual information confirming the death of the recipient or a change in the level of medical care has been prescribed by the recipient’s physician). The notice must state the action being taken, the decision of IDHS, the supporting regulations, the right to hearing, and the possible continuation of benefits pending hearing. In advance notice situations, if a recipient requests a hearing within the ten-day prior notice period, IDHS may not suspend, reduce, discontinue, or terminate benefits until a decision is rendered after hearing, unless the hearing examiner determines that the sole issue is one of law or unless the recipient has lost the benefits due to a separate change. 45 C.F.R. §205.10(a)(6); 89 Ill.Admin. Code §102.81; IDHS CASH, SNAP, AND MEDICAL POLICY MANUAL §01-06-01, www.dhs.state.il.us/page.aspx?item=4107.
In addition to the above notice requirements, long-term care applicants are entitled to receive written instructions regarding requesting of the imposition of any penalty period. PM §01-06-02.
Written notice may be sent or given in hard copy or sent electronically. IDHS may use electronic means to send written notice only if the individual to whom the notice would be sent has agreed to receive written notices electronically. 89 Ill.Admin. Code §102.70(e).
Fair Hearings
A Medicaid applicant or recipient whose Medicaid benefits are denied, terminated, or reduced is entitled to a “fair hearing,” which is a de novo review of the initial Illinois Department of Human Services decision. The applicant or recipient has 60 days to appeal an IDHS decision, whether or not it is an advance notice situation. The 60-day period runs from the issuance of the written notice. The time to appeal, however, is tolled when there is no written notice. The claimant is entitled to due process, representation, and judicial review of the hearing decision.
The applicant/recipient should file the hearing request at the local IDHS office making the decision or with the Bureau of Hearings. A recipient may also telephone a request to the Bureau of Hearings at 800-435-0774, submit an appeal by using the ABE Appeal Portal (https://abe.illinois.gov/abe/access/appeals), or mail or fax a request for appeal; however, there would be no proof of request for hearing if IDHS lost the telephone request. 89 Ill.Admin. Code §104.10. See also IDHS Brochure 377, Appeals and Fair Hearings for Those Receiving Cash, SNAP, or Medical Assistance, www.dhs.state.il.us/page.aspx?item=32119. The IDHS Request for Hearing form is available at www.dhs.state.il.us/onenetlibrary/7/documents/webcm/forms/il488-1949w.pdf, but any written request for a hearing will suffice. IDHS has required the court appointment of an executor or administrator to file an appeal after the applicant has died.
The hearing must be conducted at a reasonable time and place, with adequate preliminary written notice, by an impartial official. If a person has a disability or is hospitalized, IDHS will hold the hearing in the appellant’s home or hospital room on request. The request should be made when the appeal is filed. IDHS CASH, SNAP, AND MEDICAL POLICY MANUAL §01-07-10, www.dhs.state.il.us/page.aspx?item=4107.
Prior to the hearing, the claimant or a representative may examine the claimant’s case file at the agency, as well as all documents and records to be used by the agency at the hearing. At the hearing itself, which is conducted by an IDHS hearing officer who did not participate in the agency’s decision, the claimant or representative may present witnesses, evidence, and arguments and may confront and cross-examine adverse witnesses. The decision of the hearing officer must be based exclusively on the evidence at the hearing. Unless there is delay by the claimant, the decision must be issued and, if favorable, implemented within 90 days of the request for the hearing. 42 C.F.R. §431.244(f); 89 Ill.Admin. Code §104.70.
NOTE: IDHS rarely, if ever, issues hearing decisions within 90 days. Delays of six months or longer should be expected.
Practice in Administrative Hearings
Regulations governing practice in administrative hearings are set forth at 89 Ill.Admin. Code pt. 104, andl the policy is set forth at Illinois Department of Human Services CASH, SNAP, AND MEDICAL POLICY MANUAL §01-07-10, www.dhs.state.il.us/page.aspx?item=4107. The practice procedure is as follows:
1. An appeal hearing is conducted by an impartial hearing officer authorized by the Director of IDHS to consider the issue under appeal. The hearing is conducted in the county in which the appellant resides or, in nursing home cases, the county where the nursing home is located.
2. The Bureau of Assistance Hearings notifies the appellant and the local office of the time and place of the scheduled hearing. Note that hearings are typically conducted telephonically unless the appellant requests an in-person hearing.
3. The appellant or a representative has the right to present evidence and witnesses on the appellant’s behalf and to refute testimony or other evidence and cross-examine witnesses.
4. The hearing is not bound by rules of evidence or rules of procedure but is conducted in a manner best calculated to conform to substantial justice.
5. Subpoenas may be requested by the appellant or a representative prior to or at the hearing and are granted at the discretion of the hearing officer. The hearing officer may defer ruling on a request for a subpoena until after available evidence has been gathered and heard at the hearing.
6. The appellant or the appellant’s representative must appear at the scheduled hearing. If the appellant dies before the date of the hearing, the appeal may be continued by a representative as specified in PM §01-07-10. A signed statement to authorize a representative is not required if the appellant dies before the date of the hearing.
7. During the hearing, the appellant or the appellant’s representative may request a continuance. The continuance may be granted for a reasonable period at the discretion of the hearing officer.
8. The appellant may request a postponement in writing to the local office or the Bureau of Assistance Hearings before the scheduled hearing date. A verbal request may be made when the hearing is convened.
9. If the request is approved, the Bureau of Assistance Hearings will send the appellant or the appellant’s representative and the local office a letter (with the original appeal number) rescheduling the hearing.
Judicial Review
Appeal of a final administrative decision is made under §3-113 of the Illinois Administrative Review Law, 735 ILCS 5/3-101, et seq., by filing a complaint in the circuit court within 35 days from the date of the decision. 735 ILCS 5/3-113. Under the Administrative Review Law, the final decision of the Illinois Department of Human Services will be reversed only if it is against the manifest weight of the evidence or erroneous as a matter of law. American Federation of State, County & Municipal Employees, Council 31 v. Illinois State Labor Relations Board, State Panel, 216 Ill.2d 569, 839 N.E.2d 479, 298 Ill.Dec. 156 (2005).