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Model Application Template for the State Children's Health Insurance Program

Effective Date: August 24, 2001

Approval Date: 57 hearing at any time an action is taken affecting the rights or status of an application or recipient. Department workers also explain to applicants that they have the right to review all files relevant to their appeal, the right to appear in person at the time of the hearing, the right to be assisted at the hearing by a friend, relative, or lawyer at the applicant’s or recipient’s own cost, and the right to withdraw or abandon the hearing. Department workers explain to applicants that the request for hearing may be written or oral but that it has to be made within 30 days after the action complained of or 30 days after action should have been taken as provided by law or rule. The Department also provides an explanation of the circumstances under which eligibility may continue pending the review process. Applicants have the right to be present for all proceedings and the right to present evidence and testify at all proceedings. Applicants or recipients have the right to a written final decision within 90 days after the hearing request.

Health Services Matters

12.2 Please describe the review process for health services matters that complies with 42 CFR ∋457.1120.

Recipients of SCHIP have the same rights as recipients of the South Dakota Medicaid Program. The South Dakota Medical Assistance Program (T-19 & T-21) uses a program specific review process for eligibility and enrollment matters. The South Dakota Department of Social Services, Office of Administrative Hearings, is the impartial and external entity that conducts the administrative hearings to determine whether medical benefits are correctly denied.

A recipient of public assistance whose medical benefits are denied may appeal the action or inaction as provided in Administrative Rules of South Dakota. Individual’s rights are printed on all handbooks that are provided to the recipient. Recipients may appeal the denial by requesting a fair hearing at any time an action is taken affecting the benefits of a recipient. Department workers also explain to applicants that they have the right to appear in person at the time of the hearing, the right to be assisted at the hearing by a friend, relative, or lawyer at the applicant’s or recipient’s own cost, and the right to withdraw or abandon the hearing. Department workers explain to recipients that the request for hearing may be written or oral but that it has to be made within 30 days after the action complained of or 30 days after action should have been taken as provided by law or rule. Recipients have the right to review all files relevant to their appeal, the right to be present for all proceedings and the right to present evidence and testify at all proceedings. Recipients have the right to a written final decision within 90 days after the hearing request.

Recipients have the right to an expedited fair hearing upon presenting documentation to support that any delays under the standard time frame could jeopardize the