Effective Date: July 1, 2022

Previous Policy

1 The Department of Workforce Services (DWS) Division of Adjudications must issue a written decision to all parties involved in the hearing.

2 Send copies of the decision to the DWS Fair Hearing Team. This group is responsible to forward the decision to the individual, individual’s authorized representative and selected representatives of DWS and possibly The Department of Health and Human Services (DHHS) for review.

What Must Be Included in the Decision

A A description of the evidence that was presented.

B Finding of facts based on the evidence. The decision must be based on more than just hearsay evidence.

C Conclusions of laws and rules upon which the decision was based.

D Statement of the reason for the decision.

E Statement of action the agency must take, if any.

F Right to request an Agency Review from the DWS Division of Adjudications and how to make the request.

3 Agency Review

A DHHS, as the Single-State Medicaid Agency, is a party to all fair hearings concerning eligibility for CHIP. The DWS Division of Adjudications conducts appeals and DHHS has the right to conduct an Agency Review of CHIP hearing decisions rendered by DWS.

B The applicant or enrollee may appeal the DWS decision to DHHS. The request for agency review must be made in writing within 30 days of the mailing date of the hearing decision.

C The DWS hearing decision becomes final 30 days after the decision is sent unless DHHS will conduct an Agency Review. The DWS Division of Adjudications will conduct an Agency Review when the applicant or enrollee appeals the DWS decision, or if DHHS disagrees with the DWS decision, they will conduct an agency review.

D The DWS hearing decision may be made final in less than 30 days upon agreement of all parties.

E DHHS notifies DWS Division of Adjudications whenever it will conduct an Agency Review. The DWS hearing decision is suspended until DHHS completes their Agency Review.

F A Decision and Order on Agency Review from DHHS is reviewed a second time by the DWS Division of Adjudications, and is either agreed upon and corrected, or rejected by the DWS Division of Adjudications who’s decision is then final.

G Within 30 days of the date the Decision and Order on Agency Review was issued, the applicant or enrollee may file a petition for judicial review with the District Court. Failure to appeal a DWS Division of Adjudications hearing decision negates this right to a judicial appeal.

H Enrollees are not entitled to continued benefits pending judicial review by the District Court.

I The eligibility agency must take case action within 10 calendar days of the date the decision becomes final if the decision reverses or modifies the eligibility agency’s decision.