Or. Admin. Code § 410-200-0145

Current through Register Vol. 63, No. 11, November 1, 2024

Section 410-200-0145 - Contested Case Hearing

(1) For the purposes of this rule, timely means within 90 days of the date the notice of adverse action is received.

(2) This rule applies to contested case hearings for programs described in OAR chapter 410 division 200, except for individuals receiving HSD Medical Program benefits during a period of Hospital Presumptive Eligibility (OAR 410-200-0105). Contested case hearings are conducted in accordance with the Attorney General's model rules OAR 137-003-0501 and following ORS Ch. 183 except to the extent that Authority rules provide for different procedures.

(3) The Authority's contested case hearings governed by this rule are not open to the public and are closed to nonparticipants, except nonparticipants may attend subject to the parties' consent and applicable confidentiality laws.

(4) A claimant may request a contested case hearing upon the timely completion of a hearing request in medical assistance programs in the following situations:

(a) The Authority has not approved or denied an application within 45 days of the date of request for benefits or the extended time the Authority has allowed for processing;

(b) The Authority acts to deny, reduce, close, or suspend medical assistance, including the denial of continued benefits pending the outcome of a contested case hearing;

(c) The Authority claims that an earlier medical assistance payment was an overpayment;

(d) A claimant claims that the Authority previously under issued medical assistance;

(e) A claimant disputes the current level of benefits.

(5) An officer or employee of the Authority or the Department of Human Services may appear on behalf of the Authority in medical assistance hearings described in this rule. The Authority's lay representative may not make legal argument on behalf of the Authority.

(6) The Authority representative is subject to the Code of Conduct for Non-Attorney Representatives at Administrative Hearings, which is maintained by the Oregon Department of Justice and available on its website at http://www.doj.state.or.us. An Authority representative appearing under this rule shall read and be familiar with it.

(7) When an Authority representative is used, requests for admission and written interrogatories are not permitted.

(8) The Authority representative and the claimant may have an informal conference in order to:

(a) Provide an opportunity to settle the matter;

(b) Review the basis for the eligibility determination, including reviewing the rules and facts that serve as the basis for the decision;

(c) Exchange additional information that may correct any misunderstandings of the facts relevant to the eligibility determination; or

(d) Consider any other matters that may expedite the orderly disposition of the hearing.

(9) A claimant who is receiving medical assistance benefits and who is entitled to a continuing benefit decision notice may, at the option of the claimant, receive continuing benefits in the same manner and amount until a final order resolves the contested case. In order to receive continuing benefits, a claimant must request a hearing not later than:

(a) The tenth day following the date the notice is received; and

(b) The effective date of the action proposed in the notice.

(10) The continuing benefits are subject to modification based on additional changes affecting the claimant's eligibility or level of benefits.

(11) The claimant shall receive an expedited hearing in the following situations:

(a) When the claimant contests the denial of continuing benefits; or

(b) When following the final order timelines in OAR 410-200-0146 could jeopardize the individual's life, health, or ability to attain, maintain, or regain maximum function.

(12) In computing timeliness under sections (1) and (9) of this rule:

(a) The agency follows criteria outlined in 461-125-0310(7); and

(b) The notice is considered to be received on the fifth day after the notice is sent unless the claimant shows the notice was received later or was not received.

Or. Admin. Code § 410-200-0145

DMAP 54-2013(Temp), f. & cert. ef. 10-1-13 thru 3-30-14; DMAP 4-2014(Temp), f. & cert. ef. 1-15-14 thru 3-30-14; DMAP 20-2014, f. & cert. ef. 3-28-14; DMAP 50-2014(Temp), f. 8-14-14, cert. ef. 8-15-14 thru 2-11-15; DMAP 67-2014(Temp), f. 11-14-14, cert. ef. 11-15-14 thru 5-13-15; DMAP 3-2015, f. & cert. ef. 1/30/2015; DMAP 13-2019, temporary amend filed 05/23/2019, effective 7/1/2019through 12/27/2019; DMAP 33-2019, amend filed 08/23/2019, effective 8/23/2019; DMAP 23-2020, amend filed 05/07/2020, effective 5/8/2020

Statutory/Other Authority: ORS 411.404, 411.816, 412.014, 412.049 & 413.042

Statutes/Other Implemented: ORS 183.452, 411.060, 411.404, 411.816, 412.014 & 412.049