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Standards Used in Determining Eligibility

Medicaid eligibility determinations must be based on “ascertainable standards.” See J. Perkins, Issue brief: Appeal Rights and Medicaid Benefits citing Holmes v. New York City Hous. Auth., 398 F.2d 262, 265 (2d Cir. 1968). In Holmes, in the context of housing authority decisions, the Court said “due process requires that selections among applicants be made in accordance with “ascertainable standards.” In fair hearings, decisions
must be based exclusively on evidence introduced at the hearing. Section 431.244(a).

In early and periodic screening, diagnostic, and treatment (“EPSDT”) cases, the standard in evaluating whether services should be covered is whether the specific services are necessary to correct or ameliorate the Applicant’s physical condition. Freels, at 450. See also 42 U.S.C. § 1396d(r)(5).

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