Effective Date: July 1, 2024

Previous Policy

When an enrollee asks for a fair hearing, the enrollee may be eligible to receive CHIP benefits while the hearing is pending. Applicants cannot receive CHIP benefits during the hearing process. Continue benefits during the hearing process for an enrollee in the following two instances.

Continue CHIP assistance if the enrollee asks for a hearing any time before the effective date of the action or by the close of business on the 10th day after the date the Notice of Decision is received, whichever is later. The date which the notice is received is considered to be 5 days after the date on the notice, unless the member can show he did not receive the notice within that 5 day period.

If the 10 th day from the date the notice of decision is received is a non-business day, the enrollee has until the close of the next business day to make the request.

At the hearing or pre-hearing conference, the Hearing Officer will determine what the actual issues are. If the Hearing Officer finds the only reason for the hearing is because of Federal or State policy or law and discontinues the fair hearing process, stop the CHIP coverage. Otherwise, continue CHIP coverage until you get the hearing decision.

If the enrollee can demonstrate that he or she did not receive the Notice of Decision in the mail, mail a new notice of decision and allow the enrollee 10 days from the date this notice is received to request the hearing and continued CHIP benefits.

Enrollee’s Requirement to Repay Continued Benefits

The enrollee must repay benefits if the hearing decision goes against the enrollee. The agency must tell the enrollee of the requirement to repay benefits pending the hearing decision.

Repayment is required even if the enrollee does not use any CHIP services while the hearing is pending. This information is part of the hearing request form.

Repayment of benefits includes all expenses paid by the CHIP agency on behalf of the enrollee including fees for a CHIP Health Plan.

How to Handle Case Changes Before the Hearing Decision

When a new change happens during the continued benefits time which requires a change in CHIP coverage, adjust the coverage holding constant whatever item is the subject of the hearing. Notify the enrollee of the effect of the change. If the new change causes the enrollee to be ineligible for CHIP coverage, stop the continued benefits giving proper notice. The enrollee has the right to ask for a new hearing on the new change and may receive continued benefits if the criteria under 120-5 are met.

Appeals

Enrollees who were receiving benefits pending the hearing decision are not entitled to continued benefits during an appeal to District Court.

When to Stop CHIP Pending the Hearing Decision

An enrollee who meets the criteria to receive benefits pending the hearing decision may choose not to receive continued benefits.

Do not provide benefits pending the hearing decision or if the applicant or enrollee says he or she does not want benefits while the hearing process goes on.

The enrollee can mark the box on the hearing request form or make the request by telephone or in person to say he does not want continued benefits.

If an enrollee who initially declined the continued benefits later says he wants to receive benefits while the hearing is still in process, confirm that the hearing is still pending. Reopen the case from that point forward. Document the request. Do not open prior months. Once a hearing decision has been made, follow that decision.

If the Hearing Officer states, in writing, that the only reason for the hearing is because of Federal or State policy or law and decides not to hold a hearing, stop CHIP coverage at that time. (The Hearing Officer decides what the issues are at the hearing or pre-hearing conference.) Otherwise, provide CHIP coverage until a hearing decision is received.

If the enrollee’s whereabouts are unknown, stop the continued benefits and send notice to the last known address. Reopen the case without requiring a new application if the enrollee contacts the office within 30 days after the closure, still wants to receive benefits pending the hearing decision, and the hearing decision is still pending. If the enrollee contacts the office more than 30 days after the case is closed, reopen the case only from that point forward if the hearing is still pending.

If another change makes the enrollee ineligible, stop the continued benefits. Send appropriate notice of the closure. (See 120-5 #3 above.)

Do not provide continued benefits during an appeal to District Court. (See Section 120-8 .)