You rely on your Supplemental Security Income (“SSI”) benefits to provide much-needed financial assistance, and have consistently received the same benefit amount on the same day every month. Then one month, it isn’t there. Or, you have been relying on Medicaid benefits to cover critical health care costs, including prescriptions, and you learn that your coverage has been terminated. Can the government do that? In a word, “yes.” In fact, for all governmental assistance programs that require an eligibility application and subsequent approval, what is granted possibly can be reduced or terminated altogether. That includes Medicaid, SSI, and other programs administered at the local, state, or federal level. Reasons vary but are typically tied to program financial eligibility criteria and failure to meet one or more of those limits due to a change in your circumstances, or a failure to provide requested and required documentation. The government may also deny your initial application based on the same, although you believe you qualify.
Here’s the good news. There are certain requirements agencies must meet in notifying you of a denial, reduction, or cancellation of your benefits. And there are steps you can take to appeal a decision through an established and clear process. That too is the law.
Medicaid is a joint federal and state medical assistance program administered at the state level (typically the Department of Health and Human Services), while SSI is a federal cash assistance program managed by the Social Security Administration (SSA). While their notification process is similar, their appeals processes are quite different.
Notification should be in writing. Before any change is made to your benefit, you should be sent a letter by the responsible agency that contains the following details:
- Why you are receiving the letter.
- What the agency has determined, why they’ve made that determination, and how they arrived at their conclusion, including detailed calculations.
- What, if any, change will be made in your benefit status or payment and when it will begin.
- What action you should take if you disagree with the determination.
- How to contact the agency.
If you want to appeal a decision impacting your Medicaid benefits, the exact process differs from state to state. In New Hampshire, the Department of Health and Human Services (“DHHS”) must refer Medicaid applicants and recipients to an independent Administrative Appeals Unit which conducts an impartial hearing (also called a “fair hearing”) and makes its decision based on federal and state law. While these administrative hearings are legal proceedings, they are less formal than court hearings and those who are appealing generally are provided the opportunity to tell their story to a hearing officer. The hearing officer also reviews the documentation contained in the DHHS file and hears any relevant testimony before rendering a written legal decision. Because the hearing is a formal legal proceeding, you have the right to legal representation, to call witnesses, offer evidence, and ask questions of any witnesses DHHS produces. In some instances, a DHHS supervisor may early in an attempt to resolve the problem without a formal hearing.
Time is critical. In New Hampshire, you’ll need to request a hearing as soon as possible, but no later than 30 days after receiving the notice. If you want to request your benefits continue during your appeal process, your request must be made within 10 days. (Please note that the State of New Hampshire will need to be repaid if you lose your appeal.)
If the ruling from the hearing officer is not in your favor, you can appeal the decision through the court system. Consulting with a knowledgeable attorney will help you understand the legal merits of your appeal.
If you want to appeal an SSI determination, the Social Security Administration (“SSA”) has a detailed appeals process. From an initial determination detailed in your notification letter, you can request reconsideration by the agency. If that fails, there are several additional levels of appeal: you can request a hearing before an administrative law judge, then an appeals council review, and, ultimately Federal Court. You must request reconsideration within 60 days of receiving your initial written notice (10 days if your benefits were terminated and want your payments to continue during your appeal). The administrative hearing process itself is similar to that for Medicaid, consisting of a formal legal proceeding involving testimony, evidence, witnesses, and the opportunity to cross-examine those witnesses. If the initial level of appeal does not succeed, you can request a review by an Appeals Council within 60 days. The Appeals Council, after examining your case, can decide to grant your review, deny it, or dismiss it. If the Appeals Council does not rule favorably or denies your request, and you disagree, you may go to the U.S. District Court in your area and file a civil action within 60 days.
For more detailed information on the appeals process for Medicaid and SSI, see our earlier blog on the subject. We can only cover minimum details in the space of a blog. It is in your best interests to work with an attorney in navigating the complex appeals process and to help you determine the merits of your case. For more information on this and related topics, subscribe to our email newsletter.