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 Code of Federal Regulations (Last Updated: November 8, 2024)
 Title 42 - Public Health
 Chapter IV - Centers for Medicare & Medicaid Services, Department of Health and Human Services
 SubChapter C - Medical Assistance Programs
 Part 431 - State Organization and General Administration
 Subpart E - Fair Hearings for Applicants and Beneficiaries
 Right to Hearing

§ 431.220 - When a hearing is required.  

Latest version.

  • § 431.220 When a hearing is required.

    Cross Reference
    Link to an amendment published at 89 FR 8980, Feb. 8, 2024.

    (a) The State agency must grant an opportunity for a hearing to the following:

    (1) Any individual who requests it because he or she believes the agency has taken an action erroneously, denied his or her claim for eligibility or for covered benefits or services, or issued a determination of an individual's liability, or has not acted upon the claim with reasonable promptness including, if applicable—

    (i) An initial or subsequent decision regarding eligibility;

    (ii) A determination of the amount of medical expenses that an individual must incur in order to establish eligibility in accordance with § 435.121(e)(4) or § 435.831 of this chapter; or

    (iii) A determination of the amount of premiums and cost sharing charges under subpart A of part 447 of this chapter;

    (iv) A change in the amount or type of benefits or services; or

    (v) A request for exemption from mandatory enrollment in an Alternative Benefit Plan; or

    (vi) A prior authorization decision.

    (2) Any resident who requests it because he or she believes a skilled nursing facility or nursing facility has erroneously determined that he or she must be transferred or discharged.

    (3) Any individual who requests it because he or she believes the State has made an erroneous determination with regard to the preadmission and annual resident review requirements of section 1919(e)(7) of the Act.

    (4) Any MCO, PIHP, or PAHP enrollee who is entitled to a hearing under subpart F of part 438 of this chapter.

    (5) Any enrollee in a non-emergency medical transportation PAHP (as that term is defined in § 438.9 of this chapter) who has an action as stated in this subpart.

    (6) Any enrollee who is entitled to a hearing under subpart B of part 438 of this chapter.

    (b) The agency need not grant a hearing if the sole issue is a Federal or State law requiring an automatic change adversely affecting some or all beneficiaries.

    [44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 67 FR 41095, June 14, 2002; 67 FR 65505, Oct. 25, 2002; 81 FR 27853, May 6, 2016; 81 FR 86448, Nov. 30, 2016; 89 FR 8980, Apr. 8, 2024]