Medicaid Must Be Administered by a Single State Agency

A single state agency must be designated to administer or supervise the administration of the State Plan. 42 U.S.C. § 1396a(a)(5); 42 C.F.R. § 431.10(b)(1). Specifically, 42 U.S.C. § 1396a(a)(5) provides:

A State plan for medical assistance must—

either provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan; or provide for the establishment or designation of a single State agency to administer or to supervise the administration of the plan, except that the determination of eligibility for medical assistance under the plan shall be made by the State or local agency administering the State plan approved under subchapter I or XVI (insofar as it relates to the aged) if the State is eligible to participate in the State plan program established under subchapter XVI, or by the agency or agencies administering the supplemental security income program established under subchapter XVI or the State plan approved under part A of subchapter IV if the State is not eligible to participate in the State plan program established under subchapter XVI.

Georgia’s State Plan designates the Department of Community Health (the “Department”). In Georgia, applications are filed with the Department of Human Services, through the Division of Family and Children Services. DFCS is typically the respondent in Medicaid fair hearings, and must participate in the fair hearing since it is responsible for the eligibility determination. 42 C.F.R. § 431.243.However, the Department of Community Health is the real party in interest; appeals from a fair hearing are to DCH.

The Department must afford everyone an opportunity to apply for medical assistance. See 42 C.F.R. § 435.906. States are required to accept applications in numerous ways. 42 C.F.R. § 435.907(a) provides: In accordance with section 1413(b)(1)(A) of the Affordable Care Act, the agency must accept an application from the applicant, an adult who is in the applicant’s household, as defined in § 435.603(f), or family, as defined in section 36B(d)(1) of the Code, an authorized representative, or if the applicant is a minor or incapacitated, someone acting responsibly for the applicant, and any documentation required to establish eligibility –

(1) Via the internet Web site described in § 435.1200(f) of this part;

(2) By telephone;

(3) Via mail;

(4) In person; and

(5) Through other commonly available electronic means

“Medicaid assistance” is defined at 42 U.S.C. § 1396d(a). Among other goods and services, medical assistance includes the cost of nursing facility services for individuals 21 years of age and older who have income and resources insufficient to meet all of the cost of care. 42 U.S.C. § 1396d(a)(xvii)(4)(A).

Whether an applicant seeks Medicaid with or without the assistance of an attorney (42 C.F.R. § 435.908), an understanding of the administrative process is critical. An Applicant (see O.C.G.A. § 49-4-141(1)(defining applicant)) who is denied eligibility, who is approved for less than the coverage level sought, or who is not timely approved is entitled to a fair hearing. 42 U.S.C. § 1396a(a)(3); 42 C.F.R. § 431.220; O.C.G.A. § 49-4-153(b)(1); O.C.G.A. § 49-4-13(a).

Medicaid recipients who are terminated, or who have their benefits reduced are also entitled to a fair hearing. See O.C.G.A. § 49-4-141(7) (defining recipient). When the ABD Manual refers to an “A/R” it refers to both Applicants and Recipients. See also ABD Manual, Appendix E-2 (defining “A/R”).