16 Del. Admin. Code § 5000-5304
7 CFR 273.15, 42 CFR 431.241, 45 CFR 205.10
This policy applies to applicants and recipients for any public assistance program administered by the Division of Social Services or the Division of Medicaid and Medical Assistance. It also applies to programs administered by other agencies over which DSS has authority. Staff may not limit or interfere in any way with an appellant's freedom to make a request for a hearing.
The Division of Social Services is authorized to preside over and render decisions in the following types of hearings:
A request for a hearing must be a clear, written expression to the effect that the appellant wants the opportunity to present his or her case to a higher authority. The request must be signed by the appellant or his or her representative.
Exception: The agency must establish procedures that permit an individual, or an authorized representative, to submit a hearing request for Medical Assistance: 1. Via the internet website; 2. By telephone; 3. Via mail; 4. In person; and 5. Through other commonly available electronic means. Appellants of actions taken in the Food Supplement Program may request a fair hearing orally. If an oral request is made, inform the appellant that it is advisable to finalize the request by putting it in writing. The staff member receiving an oral request will take steps to begin the hearing process. This includes an offer, at the time of the request, to assist the appellant by putting the request in writing. |
The Hearing Officer has the authority to restrict the issues raised at the hearing. The following issues may be raised at the hearing.
15 DE Reg. 86 (07/01/11)
42 CFR 431.243
This policy applies to applicants for and recipients of residential nursing services.
Individuals adversely affected by determinations made by the Division of Substance Abuse and Mental Health (DSAMH) or the Division of Developmental Disabilities Services (DDDS) as a result of a pre-admission screening resident review PASRR may appeal the decision to the Division of Social Services (DSS). The hearing is conducted by DSS and the decision is binding on the Department of Health and Social Services.
For hearings on PASRR determinations which have a specific effect on Medicaid Program eligibility, DMMA will appear as a witness for DDDS or DSAMH if requested by a party to the hearing. Final PASRR determinations will be issued by DMMA.
For appeals initiated by non-Medicaid claimants or appellants, the State's case is presented by DDDS or by DSAMH as appropriate.
15 DE Reg. 86 (07/01/11)
12 DE Reg. 242 (08/01/08)
42 CFR 438.408(f), 42 CFR 438.410
This policy applies to recipients enrolled in a managed care organization.
Recipients of medical services from the Division of Medicaid and Medical Assistance may request a hearing from the Division after receiving an MCO's notice of appeal resolution upholding an adverse benefit determination or the MCO's failure to adhere to the notice and timing requirements in 42 CFR 438.408. The decision of the DSS Hearing Officer is a final decision of the Department of Health and Social Services and is binding on the MCO.
The MCO is responsible for the preparation of the hearing summary under § 5312 of these rules and the presentation of its case. The MCO is subject to the rules, practices, and procedures detailed herein.
These rules do not prevent an MCO from offering conciliation services or one level of appeal prior to the fair hearing conducted by DSS.
The MCO is responsible for establishing and maintaining an expedited review process for appeals when the MCO determines or the provider indicates that taking the time for standard resolution could seriously jeopardize the claimant's life, physical or mental health or ability to attain, maintain, or regain maximum function. The expedited review can be requested by the claimant or the provider on the claimant's behalf.
The MCO must provide for prompt access to MCO case records as specified in DSSM 5403. The MCO must also issue an expedited resolution within 72 hours after receiving the appeal. Expedited appeals must otherwise follow all other standard appeal requirements.
If the MCO denies a request for an expedited resolution of an appeal, it must:
15 DE Reg. 86 (07/01/11)
16 DE Reg. 419 (10/01/12)
21 DE Reg. 879 (05/01/18)
45 CFR 205.10(a)(1)
This policy applies to applicants for and recipients of Emergency Assistance Services. The Division of Social Services (DSS) is the appointed authority for Emergency Assistance Services (EAS). The program is administered by a contracted vendor. Requests for hearings on EAS eligibility decisions made by the contracted vendor are heard by DSS.
15 DE Reg. 86 (07/01/11)
This policy applies to applicants and recipients of home and community-based services provided under Delaware Medicaid Program waiver projects and managed by other Divisions within the Department of Health and Social Services.
The Division taking the action in dispute is responsible for the preparation of the hearing summary under § 5312 of these rules and the presentation of its case. The Division is subject to the rules, practices, and procedures detailed herein. The decision of the DSS Hearing Officer is a final decision of the Department of Health and Social Services and is binding on the Division.
12 DE Reg. 242 (08/01/08)
16 Del. Admin. Code § 5000-5304
27 DE Reg. 975 (6/1/2024) (Final)