Section 14. Implementation Of Decision

Unless stayed by court order, the department’s final fair hearing decision is binding on all issues that have been the subject of the fair hearing as to that claimant. The local county office is responsible for assuring that decisions are implemented within the timeframes specified below. The final fair hearing decision serves as advanced notice for changes in benefits or services. A. Decision favorable to the department: If assistance or benefits have been continued pending the outcome of the fair hearing and the decision is favorable to the department, the department shall take immediate action to adjust the payment and submit a claim for the excess benefit amount(s) paid pending the outcome of the fair hearing. B. Decision favorable to the claimant: 8.100.970 NMAC 12 (1) Cash assistance programs: When a fair hearing decision is favorable to the claimant, the department authorizes corrective payment. For incorrectly denied cases, corrected benefits are issued retroactively in the following manner: (a) to the date of adverse action or to the 30th day from the application date, whichever is earlier; or (b) to the first day of the month that the case is actually eligible for benefits; (c) for ongoing cases, the corrected cash assistance payments are retroactive to the first day of the month that the incorrect action became effective. (2) SNAP: Decisions that result in an increased benefit shall be reflected in the claimant's next authorized allotment. The final fair hearing decision serves as verification for increased benefits h that the case is actually eligible for benefits; (c) for ongoing cases, the corrected cash assistance payments are retroactive to the first day of the month that the incorrect action became effective. (2) SNAP: Decisions that result in an increased benefit shall be reflected in the claimant's next authorized allotment. The final fair hearing decision serves as verification for increased benefits. (3) Medical assistance programs: When a fair hearing decision is favorable to the claimant and a case was incorrectly denied, corrected benefits are issued retroactively in the following manner: (a) to the date of adverse action or to the 30th day from the application date, whichever is earlier; or (b) to the first day of the month that the case is actually eligible for benefits; (c) for ongoing cases, the corrected benefit is retroactive to the first day of the month that the incorrect action became effective; (d) fair hearings for medical assistance programs involving the termination, modification, reduction or suspension of services are governed by applicable federal and state law and regulations, including 8.352 NMAC, et seq. C. Implementation of decisions related to NMHIX: Unless stated by court order, the department’s final fair hearing decision is binding on all issues that have been the subject of the fair hearings as to that claimant. NMHIX, upon receiving notice of the final fair hearing decision, must promptly: (1) Implement the decision effective: (a) Prospectively, on the first day of the month following the date of the notice of appeal decision, or consistent with 45 CFR section 155.330(f)(2), (3), (4), or (5), if applicable; or (b) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under incorrect eligibility determination that is the subject of the appeal, at the option of the appellant of the month following the date of the notice of appeal decision, or consistent with 45 CFR section 155.330(f)(2), (3), (4), or (5), if applicable; or (b) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under incorrect eligibility determination that is the subject of the appeal, at the option of the appellant. (2) Redetermine the eligibility or household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in 45 CFR section 155.305. [8.100.970.14 NMAC - Rp, 8.100.970.14 NMAC, 11/27/2013; A/E, 11/1/2021; A, 4/1/2022] 8.100.970.15 JUDICIAL REVIEW A. Right of appeal: If a final fair hearing decision upholds the department’s or NMHIX’s original action, the claimant has the right to pursue judicial review of the final fair hearing decision and is notified of that right in the department’s final fair hearing decision. In matters involving NMHIX, the claimant may submit a second-tier appeal to the United States department of health and human services and is notified of that right in the department’s final fair hearing decision. B. Timeliness: (1) SNAP, LIHEAP, general assistance (GA), and medical assistance programs: Unless otherwise provided by law, within 30 days of the issuance of the department’s final fair hearing decision, the claimant may appeal the final fair hearing decision by filing a notice of appeal with the appropriate district court pursuant to the provisions of Section 39-3-1.1 NMSA 1978. (2) NMW: Unless otherwise provided by law, within 30 days of the issuance of the department’s final fair hearing decision, the claimant may appeal the final fair hearing decision by filing a notice of appeal with the court of appeals pursuant to the provisions of Section 27-2B-13 NMSA 1978. C ce of appeal with the appropriate district court pursuant to the provisions of Section 39-3-1.1 NMSA 1978. (2) NMW: Unless otherwise provided by law, within 30 days of the issuance of the department’s final fair hearing decision, the claimant may appeal the final fair hearing decision by filing a notice of appeal with the court of appeals pursuant to the provisions of Section 27-2B-13 NMSA 1978. C. Jurisdiction and standard of review: (1) The district court’s jurisdiction is defined by statute at Section 27-3-3 NMSA 1978 and Section 39-3-1.1 NMSA 1978. The court of appeals jurisdiction is defined by statute at Section 27-2B-13 NMSA 1978. (2) The court of appeals or district court may set aside, reverse or remand the department’s final fair hearing decision if it determines that: (a) the department acted fraudulently, arbitrarily or capriciously; (b) the final fair hearing decision was not supported by substantial evidence; or, 8.100.970 NMAC 13 (c) the department did not act in accordance with federal and state laws and regulations. D. Benefits pending an appeal: If the court decides in favor of the claimant, the department must immediately act in accordance with the court’s final hearing decision. If the decision is in favor of the department, the department shall take any and all appropriate actions in accordance with Subsection A of 8.100.970.14 NMAC and 8.100.640 NMAC. E. Effect of appeal: If the court of appeals decides in favor of the claimant, the HSD office of general counsel immediately notifies the county office as to the appropriate benefit issuance and adjustments, if any. If the decision is in favor of HSD, and a reduction has been pending the decision on appeal, an overpayment claim retroactive to the date the change should have been made is filed. F . E. Effect of appeal: If the court of appeals decides in favor of the claimant, the HSD office of general counsel immediately notifies the county office as to the appropriate benefit issuance and adjustments, if any. If the decision is in favor of HSD, and a reduction has been pending the decision on appeal, an overpayment claim retroactive to the date the change should have been made is filed. F. Appealing the appellant court’s decision: (1) SNAP, LIHEAP, GA and medical assistance programs: A party to the appeal to district court may appeal the district court’s decision by filing a petition for writ of certiorari with the court of appeals, which may exercise its discretion to grant review. A party may seek further review by filing a petition for writ of certiorari with the supreme court. Section 39-3-1.1 NMSA 1978. (2) NMW: A party may seek further review by filing a petition for writ of certiorari with the supreme court.