In PR v. Division of Medical Assistance and Health Services (NJ. App. Div. 6/8/2023), the State was authorized to recover Medicaid benefits incorrectly paid. It was not, however, authorized to play fast and loose by withdrawing a waiver of a portion of its claim as part of the Commissioner’s review. Peter and Uma, an unmarried […]
The collateral estoppel (issue preclusion) rule is part of the finality doctrine along with Res Judicata (claim preclusion). It general prevents a party from re-litigating the same issue in a second court. In other words, you don’t get a second bite at the apple in another court simply because you were dissatisfied with the result […]
On June 5, 2023, the Centers for Medicare and Medicaid Services (CMS) amended 42 C.F.R. § 483.80 (infection control) and § 483.430 (Condition of participation: Facility staffing) to remove expired COVID-19 provisions. See 88 FR 36485. The specific amendments are: Section 483.80 is amended by removing paragraphs (h) and (i). Section 483.430 is amended by […]
“In general, in order to maintain an action, a party “must establish standing to sue on the ground asserted, which requires showing an injury in fact that was caused by the breach of a duty owed by the defendants to the plaintiffs and that will be redressed by a favorable decision from the court.” Ames […]
In L.U. v. Division of Medical Assistance (N.J. Superior Court Docket A-2937-20, May 23, 2023), the Superior Court affirmed denial of L.U.’s request for a fair hearing. How, you ask? “I thought everyone had a right to a fair hearing!!! Well, apparently not. L.U. was an unrepresented Medicaid recipient. He appealed from a May 11, […]
The following Georgia Medicaid cases were litigated outside the context of an administrative hearing, or were appealed beyond that point. Of course, we are not representing there are no other published decisions on point. United Cerebral Palsy of Georgia v. Ga. Dep’t of Behavioral Health and Dev. Disabilities, 331 Ga. App. 616 (2015). A provider […]
An ALJ may order a prehearing conference to simplify the issues being presented. Conferences may be held in person or by telephone. Ga. R. & Regs. § 616-1-2-.14 is analogous to O.C.G.A. § 9-11-16(a) because it allows ALJs to clear up evidentiary and procedural matters before the hearing. Specifically, Rule 14 provides: (1) Conferences. The […]
All applications for ABD Medicaid require that the applicant’s basic eligibility be verified. See ABD Manual Section 2201-4. Applications for long-term care Medicaid also require verification of income and resources, but caseworkers are instructed to “For ABD Medicaid verification requirements, see the sections pertaining to the specific COA and the Income and Resource Chapters.” ABD […]
Right to a Hearing The right to a hearing is a property right and belongs to the applicant. See Bd. of Regents v. Roth, 408 U.S. 564 (1972) (“Property interests, of course, are not created by the Constitution. Rather, they are created and their dimensions are defined by existing rules or understandings that stem from […]
Taking over a case started by someone else is never my preference. It’s far easier to do something correctly the first time. So what do you do when you’re brought in to fix a case. You pray! First, if someone hires you and no decision has been made, review the file. If there is an […]
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