80.03 Right to a State fair hearing

When a State fair hearing is required.5 AHS will grant an opportunity for a State fair hearing to any individual who requests it because AHS terminates, suspends, denies or reduces their eligibility, reduces their level of benefits or services, their claim is not acted upon with reasonable promptness, they are aggrieved by any other action taken by AHS affecting their receipt of assistance, benefits or services or by agency policy as it affects their situation, or they believe an action or decision by AHS has been taken erroneously. This includes, if applicable: (1) A determination of the amount of medical expenses which must be incurred to establish Medicaid eligibility in accordance with § 7.03(a)(8) or § 8.06; (2) A determination of income for the purposes of imposing Medicaid premiums and cost-sharing requirements; (3) A determination for any month that an individual is ineligible for APTC because the individual is considered eligible for other MEC under § 12.02(b) and § 23.00. This includes, but is not limited to, determinations of affordability and minimum value for employer-sponsored plans; (4) An initial determination of eligibility, including the amount of APTC, the Vermont Premium Reduction and level of federal or state CSR; (5) A redetermination of eligibility, including the amount of APTC, the Vermont Premium Reduction and level of federal or state CSR; (6) A failure by AHS to provide timely notice of a determination; and (7) A determination of eligibility for a special enrollment period. (b) Exception: SSI enrollees. An applicant for or recipient of SSI/AABD benefits who is denied SSI/AABD benefits or has their SSI/AABD benefits terminated because the SSA or its agent found the individual to be not disabled, may not appeal the Medicaid denial or termination that results from this action by the SSA or its agent to the Human Services Board (see Disability Determination Appeal under § 81.00). (c) Exception: Mass changes. There is no right to a State fair hearing or an expedited eligibility appeal when either state or federal law requires automatic case adjustments for classes of enrollees, unless the reason for an individual’s appeal is incorrect eligibility determination. 5 42 CFR § 431.220; 45 CFR § 155.505. State fair hearings/expedited eligibility appeals Part 8 – Page 3 (Sec.80.00, Sub.80.04)