Appeals for Waiver Beneficiaries Receiving Medicaid Services

Appeals for Waiver Beneficiaries Receiving Medicaid Services A. Appeal Procedure for Waivers Administered by the Mississippi Department of Rehabilitative Services (MDRS). 1. MDRS administers benefits for the following waivers: a) Independent Living (IL) Waiver, and b) Traumatic Brain Injury/Spinal Cord Injury (TBI/SCI) Waiver, 2. A Case Manager sends a Notice of Action (NOA) to a beneficiary via certified mail informing the beneficiary that benefits have been denied. a) The beneficiary/beneficiary’s representative may request to present an appeal within thirty (30) days. This appeal request may ask for a local hearing, state hearing, or both. b) The beneficiary/beneficiary’s representative may choose to represent themselves or designate another representative in writing. 3. Local Hearing a) For the IL and TBI/SCI, local hearings will be conducted by MDRS. MDRS will issue a determination within thirty (30) days of the initial request. b) If the beneficiary/beneficiary’s representative is dissatisfied with the of the local level determination for any of the waivers listed, the beneficiary/beneficiary’s representative may request a state hearing with the Division of Medicaid through the methods described in Part 300, Chapter 2, Rule 2.16: State Hearing Requests After Adverse Local Decision. Requests must be made within fifteen (15) days of the adverse decision. 4. State Hearing a) State hearings are conducted by the Division of Medicaid. b) The beneficiary/beneficiary’s representative may either: 1) Request a state hearing at the beginning of the appeal process, or 2) Request a state hearing within fifteen (15) days after receiving a local level determination with which the beneficiary/beneficiary’s representative is dissatisfied. (a) For beneficiaries receiving services through the Traumatic Brain Injury/Spinal Cord Injury Waiver, the request must be made within fifteen (15) days from the date the determination letter was mailed. (b) For beneficiaries receiving services through the Independent Living Waiver, the request must be made within fifteen (15) days from the date the letter wasreceived. c) State hearings for wavier beneficiaries will be conducted in the same manner as state hearings for all Division of Medicaid beneficiaries who request a state hearing, as described in Part 300, Chapter 2, Rule 2.18 of this Title. d) The Division will issue a determination within ninety (90) days of the hearing request. Both the Division and MDRS will inform the beneficiary/beneficiary’s representative of the decision in writing. This decision is final and not appealable to MDRS or the Division of Medicaid. B. Appeal Procedures for Waivers Administered by the Mississippi Department of Mental Health (DMH). 1. DMH administers the Intellectual Disabilities/Developmental Disabilities (ID/DD) Waiver. 2. At any point in the DMH appeal process, the beneficiary/beneficiary’s representative may request a state hearing through the Division of Medicaid. 3. Beneficiaries are notified of level of care (LOC) or eligibility denials within ten (10) days of the denial of eligibility for the LOC. The beneficiary has thirty (30) days from the date of the notice to submit an appeal to the Director of the Bureau of Intellectual Disabilities/Disabilities (BIDD). Appeals must be submitted in writing. 4. During the appeal process, contested services that were already in place must remain in place, unless the decision is for immediate termination due to possible adverse circumstances to the beneficiary. 5. The BIDD Director will respond in writing within thirty (30) days of receipt of the appeal. If more information is needed, the BIDD Director may request additional information before making a decision and extend the thirty (30) day timeline. 6. If the beneficiary/beneficiary’s representative is dissatisfied with the BIDD Director’s decision, the beneficiary/beneficiary’s representative may appeal to the Executive Director of DMH in writing by the date noted in the decision letter. Appeals must be submitted in writing. 7. The Executive Director of DMH will respond in writing within thirty (30) days of receipt of the appeal. If more information is needed, the Executive Director of DMH may request additional information before making a decision and extend the thirty (30) day timeline. 8. If the beneficiary/beneficiary’s representative is dissatisfied with the Executive Director of DMH’s decision, the beneficiary/beneficiary’s representative may appeal to the Executive Director of Medicaid for a state hearing in writing within thirty (30) days of receiving notification of the decision. 9. State Hearing a) State hearings are conducted by the Division of Medicaid. b) The beneficiary/beneficiary’s representative may either: 1) Request a state hearing at any point in the appeal process, or 2) Request a state hearing within thirty (30) days after receiving a local level determination with which the beneficiary/beneficiary’s representative is dissatisfied. c) State hearings for waiver beneficiaries will be conducted in the same manner as state hearings for all Division of Medicaid beneficiaries who request a state hearing, as described in Part 300, Chapter 2, Rule 2.18 of this Title. d) The Division will issue a determination within ninety (90) days of the hearing request and inform the beneficiary/beneficiary’s representative and DMH of the decision in writing. e) If the beneficiary/beneficiary’s representative is dissatisfied with Division of Medicaid’s decision, the beneficiary/beneficiary’s representative may seek relief in a court of proper jurisdiction. C. Appeal Procedures for Waivers Administered by the Mississippi Division of Medicaid. 1. The Division of Medicaid administers the following waivers: a) Elderly and Disabled (ED) Waiver, and b) Assisted Living (AL) Waiver. 2. A Case Manager sends a Notice of Action (NOA) to a beneficiary via certified mail informing the beneficiary that benefits have been denied. a) The beneficiary/beneficiary’s representative may request to present an appeal within thirty (30) days of the date of the denial notice. This appeal request may ask for a state hearing. b) The beneficiary/beneficiary’s representative may choose to represent themselves or designate another representative in writing. 3. State Hearing a) State hearings are conducted by the Division of Medicaid, Office of Appeals. b) State hearings for waiver beneficiaries will be conducted in the same manner as state hearings for all Division of Medicaid beneficiaries who request a state hearing, as described in Part 300, Chapter 2, Rule 2.18 of this Title. c) The Division will issue a determination within ninety (90) days of the hearing request. The Division will inform the beneficiary/beneficiary’s representative of the decision in writing. If the person/legal guarding determines the need for further redress, he/she may seek relief in a court of appropriate jurisdiction.