Change to AHCA Medicaid Appeals Beginning March 1, 2017
Section 409.285(2), Florida Statutes, states:
Appeals related to Medicaid programs directly administered by the Agency for Health Care Administration, including appeals related to Florida’s Statewide Medicaid Managed Care program and associated federal waivers, filed on or after March 1, 2017, must be directed to the [Agency for Health Care Administration] in the manner and form prescribed by the agency…”
For Medicaid service determinations on March 1, 2017 or after, the Office of Appeal Hearings will no longer accept fair hearing requests for Medicaid programs administered by the Agency for Health Care Administration (AHCA). Fair hearing requests made on or after March 1, 2017 must be directed to AHCA, who can be contacted at:
Agency for Health Care Administration
Medicaid Hearing Unit
P.O. Box 60127
Ft. Myers, FL 33906
Telephone: (877) 254-1055 (toll-free)
Fax: (239) 338-2642
This information is being provided by the Office of Appeal Hearings to explain to you the administrative hearing process used by hearing officers of the Department of Children and Families, under Chapter 120, Florida Statutes, and to help you prepare for a hearing.
It is important to remember that the information presented is general and is intended to cover the usual situation. The explanations do not cover all situations that may arise in a case. You should also consult the Florida Administrative Procedures Act, Chapter 120, F.S., rules of the Office of Appeal Hearings, Chapter 65-2.042, Florida Administrative Code, the federal regulations for Medicaid at 42 C.F.R. 431.200 or for the Food Stamp Program at 7 C.F.R. 273.15, 273.16.
WHAT IS THE OFFICE OF APPEAL HEARINGS?
The Office of Appeal Hearings is part of the Office of Inspector General within the Department of Children and Families. The office employs full time hearing officers to conduct hearings for cases in which an action, intended action or failure to act would adversely affect the individual's or family's eligibility for an amount or type of Financial Assistance, Medical Assistance, Social Services, or Food Stamp Program Benefits; or where action on a claim for such assistance or services is unreasonably delayed. These hearings are generally referred to as "Fair Hearings" in federal regulations.
Requests for hearings can be made at the local office or directly to the Office of Appeal Hearings. The office provides a hearing conducted by an independent and neutral hearing officer who writes a decision based on program rules and regulations, the facts or evidence produced during the hearing, and post-hearing submissions, if submitted, in the form of a Final Order.
WHAT NOTICES WILL I RECEIVE FROM THE OFFICE OF APPEAL HEARINGS?
Unless the case is dismissed by Order of the hearing officer, you will receive a Notice of Hearing. In most cases, notice will be sent at least 14 days prior to the date of hearing. The Notice of Hearing will advise you of the time, date and place of the hearing and some basic information and hearing procedures. You will receive the Final Order from the hearing officer after the completion of the hearing, unless you withdraw or abandon your case. If your address changes, be sure to notify the hearings office in writing so that you can be properly notified about the hearing date and receive your copy of the Final Order.
WHERE WILL THE HEARING BE HELD?
There are three different ways hearings are held. One: all individuals appear before the hearing officer in a local office. Two: you the Department's representative and all witnesses attend at a local office and the hearing officer appears by telephone. Three: all individuals attend the hearing by telephone. If you want to appear personally before the hearing officer, please contact the Office of Appeal Hearings by telephone or in writing to let the hearing officer know of your request. The Notice of Hearing will tell you how the hearing has been scheduled.
WHAT IF THE HEARING IS SCHEDULED FOR A TIME WHEN YOU ARE NOT AVAILABLE?
If it is impossible for you to attend the hearing at the scheduled time, you must immediately request a continuance from the hearing officer. Except for extreme emergencies, the request should be made at least 5 days prior to the hearing date.
DO I HAVE THE RIGHT TO SEE INFORMATION HELD BY THE OTHER PARTIES TO MY CASE?
You can review your case file for information or documents that will relate to the issue(s) that will be discussed at the hearing and decided by the hearing officer. The review should take place at the Department's office. You may obtain copies of documents in the file. If the Department refuses to provide information to you, you may contact the hearing officer who will determine the appropriateness of your request.
HOW AM I REPRESENTED AT THE HEARING?
You may represent yourself or be represented by another person, including an attorney. If you want legal representation, you may qualify for free legal services in your community, otherwise, you would be responsible for paying your attorney for their services or advice. If you are not present at the hearing, the person you authorized to represent you must have written authorization from you to do so. If you are represented by an attorney, ask the attorney to file a notice of appearance with the hearing officer and the Department's or Agency's legal counsel.
HOW SHOULD I PREPARE FOR THE HEARING?
In preparing for the hearing, it may be helpful to make a list of all the information which relates to your case and which you may want the hearing officer to consider. You will need to submit the documentary evidence to hearing officer and copy to the Department at least seven days prior to the hearing.
Persons who have knowledge of your case should be asked to attend the hearing and testify on your behalf. If you believe it to be necessary to ensure that a person attends your hearing, subpoenas will be issued for such individuals on your behalf. You may request subpoenas from the hearing officer. The request must be in writing. You have the responsibility to show the subpoenas have been lawfully served on the person you are trying to have attend and participate at your hearing. If you need the testimony of a person who is an expert, such as a doctor, you may also ask that person to attend the hearing and testify. However, you may have to pay the expert a fee, as determined by the expert.
WHAT WILL HAPPEN AT THE HEARING?
In each case, the hearing officer will decide who will present evidence first and how the hearing will proceed. This decision will be based on which party is requesting the action and on what would be the most practical and orderly way to explain your case to the hearing officer. Before the actual presentation of evidence begins, the hearing officer will explain the procedures that will be followed. If you are confused about the procedures or other matters, you should let the hearing officer know. You may ask questions about the procedures at any appropriate time during the hearing.
The hearing officer will allow each party to present witnesses and other evidence. The hearing officer will also permit each party to question the other party’s witnesses. This is called “cross-examination.” All relevant evidence may be presented, including hearsay. Hearsay is generally statements made by witnesses during the hearing that were made by another person before the hearing. However, the hearing officer cannot base a finding of fact on hearsay alone. The hearing officer may limit presentation of evidence if it is repetitive or not relevant to the issue(s) to be decided by the hearing officer.
A record of everything that is said will be made at the hearing, so it is important that you speak clearly and loud enough to be heard by everyone present at the hearing. The record will be preserved by electronic recording.
The hearing officer is an impartial, independent person who has not been involved in the action, inaction, or decision to be considered by the hearing officer and who does not have any personal interest in the outcome of the matter. The hearing officer will attempt to determine the truth and to understand and fairly evaluate the position of each party. In doing so, the hearing officer may ask you questions about what happened, the agency representative, or any witness at the hearing.
WILL THE HEARING OFFICER ASK FOR ADDITIONAL INFORMATION AFTER THE HEARING?
In some cases, the hearing officer may ask for or permit the parties to submit additional documents after the hearing. If you want to submit a proposed written decision after the hearing which you believe should be the order of the hearing officer, you must tell the hearing officer before the close of the hearing that you want to submit a written statement. The hearing officer will establish a deadline for your submission.
WHEN WILL I RECEIVE THE HEARING OFFICER’S ORDER?
The deadline for making a decision is generally set by federal program requirements. Deadlines are set based on the date of receipt of the hearing request by the State agency and are as follows: Food Stamp Program decisions -- 60 days, Medicaid Program -- 90 days, and Cash Assistance -- 90 days. The time limits can be extended in certain circumstances.
If the final decision is not in your favor, you have the right to appeal to an appropriate District Court of Appeals within 30 days of the date of the Final Order. The Florida Rules of Appellate Procedure provide the procedures for filing the appeal. You may also want to contact the court for assistance with its requirements.
WHAT IF I DECIDE THAT I DO NOT WISH TO PROCEED WITH MY HEARING?
If you decide, at any time, that you do not want to proceed with your hearing, you need to call the hearing officer and follow up in writing that you are withdrawing your request for hearing, and the hearing officer will close the hearing file as withdrawn. You should understand that if you withdraw your hearing request, the agency action would become final and binding on you and the agency.
WHAT WILL HAPPEN IF I DO NOT APPEAR AT THE HEARING?
If you do not appear at the time and place of the hearing, you must call the hearing officer immediately to explain why. If you do not contact the hearing officer, the hearing will be considered abandoned. The hearing officer will take no further action on the case and notify the local office that the case was abandoned.
If an emergency arises on or before your hearing date and you will be late for the hearing, you should attempt to telephone the hearing officer at the hearing location and explain the problem. If you cannot reach the hearing officer at that location, call the hearing office in Tallahassee and explain the problem.
AMERICANS WITH DISABILITIES ACT
In accordance with the Americans with Disabilities Act, persons needing a special accommodation to participate in their hearing should contact the hearing office no later than seven days prior to the hearing.
If your request for hearing is related to your application for/or receipt of Food Stamp benefits in accordance with Federal laws and U.S. Department of Agriculture (USDA) policy, the Department is prohibited from discrimination on the basis of race, color, national origin, age, sex, disability, political beliefs, or religion. To file a complaint of discrimination write to: USDA Director, Office of Civil Rights Room 326-W, Whitten Building, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, or call (202) 720-5964.
The hearing office may be contacted by telephone at (850) 488-1429, by Fax at (850) 487-0662, in writing at Department of Children and Families, Office of Appeal Hearings, Building 5, Room 255, 1317 Winewood Boulevard, Tallahassee, FL 32399-0700 and by email at firstname.lastname@example.org.