Continuation of Benefits

Continuation of Benefits When an applicant/beneficiary or representative requests a hearing within the Advance Notice Period, benefits must be continued or reinstated to the benefit level in effect prior to the planned adverse action, if a timely request is filed. A. Timely Request for Continuation of Benefits. 1. To determine if the request for continuation of benefits is timely, the request must be received by the regional office within ten (10) days from the notice date of the adverse action. 2. Any hearing requested or dated after this period will not be accepted as a timely request for continuation of benefits. B. Continuation of Benefits When Local Decision is Adverse. 1. The applicant/beneficiary may request a state hearing if the local hearing is adverse. 2. If benefits have been continued pending the local hearing, then benefits will continue pending a state hearing decision as long as the request for the state hearing is made within fifteen (15) days of the date on the Notice of Local Hearing Decision. C. Agency Action Upheld in Final Hearing Decision. 1. When the final hearing decision is adverse to the applicant or beneficiary, the Medicaid specialist will terminate or reduce the continued benefits using the original reason for the adverse action. 2. A second (2nd) Notice of Adverse Action is not required. D. When an adverse action is ultimately upheld, the Division of Medicaid has the right to initiate recovery procedures against the applicant or beneficiary to recoup the cost of any medical services furnished the applicant or beneficiary, to the extent they were furnished solely based on the provision for continuation of benefits.