460 IAC 17-5-10 Appeals

Sec. 10. (a) Except as provided in subsection (b), applicants, participants, or their CHOICE representative shall have a right to appeal decisions regarding CHOICE eligibility and services if: (1) they are found ineligible for the CHOICE program; (2) they disagree with the decision either to deny a service which they believe they should receive or to discontinue or reduce a particular service which they are currently receiving; and (3) they believe that any decision made or action taken concerning the CHOICE services they receive was not appropriate or in their best interests. (b) The case manager is responsible for answering questions and attempting to resolve any problems or complaints before the applicant or participant resorts to the appeal process. The case manager is also responsible for documenting all complaints and actions taken in the case file in order to create a complete record for appeal. (c) In case of applicants or participants who lack the capacity to make a knowing and informed decision regarding their own care, their CHOICE representative may appear on their behalf throughout the appeals process. (d) Individuals or their CHOICE representative shall comply with the following appeals process: STEP ONE: Individuals or their CHOICE representative shall first discuss any questions, concerns, or problems regarding CHOICE services with the case manager and the case manager supervisor. This informal meeting may take place either at the agency or at the applicant's or participant's home. The applicant or participant may be accompanied by an advocate. Within five (5) working days of the date of the informal meeting, the case manager supervisor shall inform the applicant or participant in writing of the decision reached on the issues raised at the meeting. The case manager supervisor shall also inform the applicant or participant that he or she may request an agency review to the AAA's executive director or designee within eighteen (18) calendar days of the date of the case manager supervisor's decision. STEP TWO: Agency review as follows: (A) The executive director or his or her designee shall conduct the agency review at the applicant's or participant's home or at the AAA office, whichever is more convenient for the applicant or participant. The applicant or participant, his or her advocate (if desired), and the case manager or the case manager's supervisor shall attend the review. (B) Applicants and participants shall be given the opportunity to testify, present supporting materials, and explain why they disagree with the action or decision and what they would view as an appropriate alternative. The case manager or case manager supervisor may testify and explain the reasons for the decision or action taken. (C) Immediately following the review, the executive director or designee conducting the review shall consider the comments of the applicant or participant, his or her advocate, and the case manager or the case manager's supervisor. (D) Within five (5) working days, the executive director, or designee after consulting with the executive director, shall prepare the agency's final decision, in writing, including findings of fact and the specific reason for the decision. The applicant or participant and his or her advocate, if any, shall each be sent a copy of the decision by registered or certified mail, return receipt requested. The decision shall inform the applicant or participant of his or her right to have an administrative hearing under STEP THREE if dissatisfied with the agency's final decision. STEP THREE: Administrative hearing as follows: (A) If an applicant or participant is dissatisfied with the decision reached at the agency review, then he or she may appeal the decision by requesting an administrative hearing. The applicant, participant, or CHOICE representative shall make the request for an administrative hearing, in writing, including a statement of the issues the applicant or participant wishes reviewed. The request shall be signed and dated. The written request shall be sent to the deputy director of the division, bureau of aging and in-home services within eighteen (18) days of the date of the decision from the agency review. (B) Administrative hearings shall be conducted by administrative law judges (ALJs), or hearing officers, appointed by the DDARS director. The ALJ shall notify the applicant or participant and all involved persons of the date, time, and location of the hearing at least five (5) working days in advance. The applicant or participant shall be notified by registered or certified mail, return receipt requested. The AAA shall forward all written case documentation to the ALJ prior to the date of the hearing. The hearing shall be conducted in accordance with IC 4-21.5-1. (C) Immediately, but no later than five (5) days following the hearing, the ALJ shall prepare the proposed decision, including a report of the findings of fact and the reasons for the decision based on those findings of fact. In accordance with IC 4-21.5-3-27, the ALJ shall forward the proposed decision to the DDARS director. A copy of the proposed decision shall be sent to the AAA, the applicant or participant, and his or her advocate, if any, by registered or certified mail, return receipt requested. (D) The director of the division shall either affirm, modify, or dissolve the ALJ's proposed decision. The AAA, the applicant or participant, and his or her advocate shall be notified of the director's final order by registered or certified mail, return receipt requested. (e) If a participant appeals a decision that terminates any service that is already being provided, then the service in question will usually be continued until the appeal is resolved, unless: (1) the services would be harmful to the participant; or (2) the services violate state or federal law or regulations and internal policies of the CHOICE program or the division. (f) An applicant or participant may bring to his or her informal review, agency review, and administrative hearing any person he or she wishes to be present, including legal counsel. The division shall not pay for legal counsel for an applicant or participant during the appeal process. (g) Interpreter services will be made available to assist the deaf or non-English speaking person upon request. Reader services will be made available to assist the blind person upon request. However, if the applicant or participant requires these services for participation in the agency review or administrative hearing, the applicant or participant, prior to the date of the review, shall discuss the arrangements with the case manager. (h) The AAA shall have in place at all times an appeals process that complies with this section.