A person aggrieved by a proposed or actual Agency action may request a hearing in accordance with Chapter 3 of the Alabama Medicaid Administrative Code. A recoupment action will not be abated during the time for a requesting a hearing. The Agency may at its discretion suspend a recoupment action until after a hearing is held.

EXHIBIT A

STATE OF ALABAMA

COUNTY OF

LIEN FOR MEDICAL PAYMENTS UNDER

ALABAMA MEDICAID PROGRAM

WHEREAS,________________________________________________,

("Medicaid Recipient")

is justly indebted to the Alabama Medicaid Agency ("the Agency") to the extent that the Agency has paid medical benefits for Medicaid Recipient under the Alabama Medicaid Program ("the Program"); and

WHEREAS, Medicaid Recipient may hereafter become indebted to the Agency to the extent that the Agency pays future medical benefits for Medicaid Recipient;

NOW, THEREFORE, in order to secure the repayment of said indebtedness and in order for Medicaid Recipient to obtain medical benefits under the Program, the Medicaid Recipient, joined by (his)(her) spouse does hereby GRANT, BARGAIN, SELL, ASSIGN and CONVEY unto the Agency, its successors and assigns, a lien for the full dollar value of said medical benefits paid and to be paid, on the following described real estate situated in __________________________County, Alabama, to-wit:

Subject, however, to all existing liens now on said property.

Notice of this lien will be recorded in said county and the dollar value of this lien as it may exist from time to time, may be obtained by writing to: Commissioner, Alabama Medicaid Agency, 2500 Fairlane Drive, Montgomery, AL 36130. This lien shall be due and payable upon the sale, transfer or lease of said property, or upon the death of Medicaid recipient, and shall otherwise be enforceable in accordance with the limitations of 42 USCA § 1396a(18) as the same may be amended.

IN WITNESS WHEREOF, the undersigned (has) (have) duly executed this instrument to voluntarily grant the aforesaid lien on this the_____day of________________, 19___.

________________________________ ___________________________

Spouse                   Medicaid Recipient

Witness:_______________________

STATE OF ALABAMA

COUNTY OF

I, the undersigned, a notary public in and for said state and county, hereby certify that _____________________________,

whose name as an Alabama Medicaid recipient, a (single) (married) person, is signed to the foregoing instrument, and

____________________ (his)(her) spouse, whose name is also signed to said instrument, acknowledged before me on this day that being informed of the contents of said instrument (they)(he)(she) executed the same voluntarily on the day the same bears date.

Given under my hand and official seal this the __________

day of_______________, 19____.

1. (SEAL) __________________________

   Notary Public

Author: Keith Thompson, Director, Third Party Liability

Statutory Authority: Social Security Act; State Plan; 42 C.F.R. Parts 431, 433, 455; AAC Rule 560-X-3-.01, et seq..

Editor’s Note: Rule .05 was renumbered .07 as per certification filed December 11, 2015; effective January 25, 2016.

History: Rule effective October 1, 1982. Amended: Filed December 11, 2015; effective January 25, 2016.