OPINION
A сlass composed of persons who applied for Medicaid, were denied, and ap *579 pealed the denial brought an action against the Indianа Family and Social Services Administration (“FSSA”). The class alleged FSSA violated the due process rights of Medicaid claimants with its policy that prohibits claimants from offering at the appeal hearing evidence of their disabilities that was not included in the initial application. The trial court granted FSSA’s motion to dismiss. We reverse.
FACTS AND PROCEDURAL HISTORY
Medicaid is a federal-state cooperative program to provide medical assistance to persons with insufficient resources or inсome to pay for the services they need. If a state chooses to participate in the program, as Indiana has, it is bound by the statutory and regulatоry requirements of the program. In Indiana, FSSA’s Medicaid Medical Review Team (MMRT) makes initial eligibility determinations. The MMRT relies on information gathered by county casеworkers who work with the applicant. The applicant is asked for information about his or her medical history, functional limitations, educational background, and employment history.
A person whose application is denied may ask for a hearing before an administrative law judge (ALJ). Pursuant to FSSA policy, the ALJ will not accept testimony or evidence about disabling conditions at the hearing if that information had not been presented in the application for benefits оr assembled by caseworkers.
The Class representatives applied for Medicaid and were denied benefits after the MMRT reviewed the medical informаtion, statements, and other records they provided. The members requested a review of the denial by an ALJ. The ALJ would not accept evidence unrelated to conditions presented in the application or information not gathered before review by the MMRT.
DISCUSSION AND DECISION
A motion to dismiss pursuant to Ind. Trial Rule 12(B)(6) for failure to statе a claim on which relief can be granted tests the legal sufficiency of a claim, not the facts supporting it.
Godby v. Whitehead,
In determining whether any facts will support thе claim, we look only to the complaint and may not resort to any other evidence in the record. Id. A plaintiff need plead only the operativе facts involved in the litigation. Id. The plaintiff must provide a clear and concise statement that will put the defendants on notice as to what has taken place and the theory the plaintiff plans to pursue. Id. We cannot say the facts alleged in the complaint before us are incapable of supporting relief under any set of circumstances. Dismissal was therefore error.
A state’s Medicaid hearing system must provide for a hearing before the agency or an evidentiary hearing at the local level, with a right to an appeal hearing. 42 C.F.R. § 431.205. The hearing system must meet the due process standards set forth in
Goldberg v. Kelly,
42 C.F.R. § 431.232 provides if the decision of a local evidentiary hearing is adverse to the аpplicant or recipient, the agency must “[i]nform the applicant or recipient of his right to request that his appeal be a de novo hearing.” (Emphasis supplied.) Under § 431.240,
If the hearing involves mеdical issues such as those concerning a diagnosis, an examining physician’s report, or a medical review team’s decision, and if the hearing officer considers it necessary to have a medical assessment other than that of the individual involved in making the original decision, such a medical assessment must be obtаined at agency expense and made part of the record.
Under § 431.242, the applicant must be given an opportunity to:
(a) Examine at a reasonable time before the date of the hearing and during the hearing:
(1) The content of the applicant’s or recipient’s case file; and
(2) All documents and records to be used by the State or local agency or the skilled nursing facility or nursing facility at the hearing;
(b) Bring witnesses;
(c) Establish all pertinent facts and circumstances;
(d) Present an argument without undue interference; and
(e) Question or refute any testimony or evidence, including oрportunity to confront and cross-examine adverse witnesses.
Our own Medicaid statutes explicitly permit the ALJ to receive additional evidence in the Medicaid hearing: “At the hearing, the applicant and county office may introduce additional evidence.” Ind.Code § 12-15-28-4. 1
The Class representatives note duе process, and the Medicaid regulations, require a
de novo
hearing. They also note the hearing is not to be “adversarial”— instead, the goal of the agency is tо assure that claimants who deserve benefits get them. They argue limiting a claimant to information submitted in the original application is inconsistent with those standards.
See Gomolisky v. Davis,
The Medicaid regulations explicitly refer to a
de novo hearing.
A number of courts have distinguished between
de novo review,
which would not permit consideration of new evidence, and a
de novo hearing,
which would. Under
“de novo
review,” the appellate court steps into the trial court’s
*581
position,
reviews the same trial record,
and redecides the issue, determining whether the trial court’s decision was right or wrong.
Hutch v. State,
107 Hawai’i 411,
A
hearing de novo,
by contrast, is generally not limited to the record below. Our Supreme Court said in
Russell v. Johnson,
In light of the purpose behind the Medicaid fair hearing regulations—-to ensure that applicants have an opportunity to present evidence supporting their claims for benefits—and the authority to the effect the
“de novo
hearing” required by the regulations is one where additional evidence may be received, we cannot say the facts alleged in the complaint are “incapable of supporting relief under any set of circumstances.”
Godby,
Reversed.
Notes
. In its brief, FSSA does not acknowledge that section or any other provisions оf our Medicaid hearing statutes. Instead, it offers this provision of the Administrative Orders and Procedures Act, which requires an ALJ to exclude "irrelevant” evidence: "Upоn proper objection, the administrative law judge shall exclude evidence that is irrelevant, immaterial, unduly repetitious, or excludable on constitutionаl or statutory grounds or on the basis of evidentiary privilege recognized in the courts. In the absence of proper objection, the administrative law judge may exclude objectionable evidence.” Ind.Code § 4-21.5-3-26. FSSA characterizes the additional evidence offered by the class representatives as irrelevant.