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HB 229 Tackles Problems of Backlogged and Unfair Medicaid Appeals

Both federal and state law grants Medicaid members and applicants the right to a fair hearing when Medicaid services are denied for reasons such as eligibility determination, frequency, or duration or intensity of services.  When a Medicaid member is denied coverage he or she may dispute the denial by filing an appeal and request for a hearing with the Department of Community Health (DCH), the state agency that administers the Medicaid program.  DCH processes the request and forwards it to the Office of State Administrative Hearings (OSAH) for a hearing before an administrative law judge (ALJ).  The ALJ listens to testimony, reviews the evidence, and reaches an impartial decision.  Federal law requires that when a Medicaid member requests an appeal a final decision must be made within 90 days, absent extenuating circumstances.

Delayed and unprocessed appeals requests work to deny individuals the right to a timely appeal.  Many Georgia families have experienced very long delays in obtaining decisions on their appeal requests because DCH has failed to promptly refer their cases to the ALJ for hearing.  Some individuals, particularly those whose medical services are being reduced or denied, may become increasingly ill while they wait. Many Medicaid members wait much longer than 90 days to have their cases resolved.  H.B. 229 requires that DCH process appeals requests and refer them for hearing before an ALJ within 15 days.

Currently, after the ALJ hears a case and renders an impartial decision, DCH may appeal the decision to itself.    Under Georgia law, DCH can “affirm, modify or reverse” the judge’s decision.  This creates three problems: 1) it wastes time by adding at least 60 days to the appeal process; 2) it undermines the integrity of an appeal process that is supposed to be impartial and fair; 3) it wastes resources to have a full-blown hearing only to have department change the decision.  In other agency hearings (including child support, special education, and Department of Natural Resource appeals), the judge’s decision is final.

H.B. 229 removes DCH’s ability to overturn the ALJ’s decision.  An impartial ALJ’s decision is respected and stands as the Final Administrative Decision.  If either DCH or the Medicaid member disagree with the ALJ’s, they may appeal to Superior Court.

H.B. 229 provides a fair and efficient administrative appeal process that protects the integrity and impartiality of the hearing before the administrative law judge.