10908

10908.1 The Department shall provide timely notice of eligibility and enrollment determinations and the right to appeal the determination to applicants and beneficiaries of FCEP CHIP consistent with the requirements set forth in federal and District law and rules, including 42 C.F.R. Part 431, Subpart E, 42 C.F.R. § 435.917, and D.C. Official Code §§ 4-205.55 and 4-210.01.

10908.2 The Department shall provide timely and adequate notice to applicants and beneficiaries of FCEP CHIP in cases of intended adverse action such as an action to deny, discontinue, terminate, or change the manner or form of medical assistance.

10908.3 An adequate notice shall include:

1. (a) A statement of the intended action(s);
2. (b) The reason(s) for the intended action(s);
3. (c) Specific law and regulations supporting the action, or the change in federal or District law that requires the action(s);
4. (d) An explanation of an applicant or beneficiary's right to request an administrative review or fair hearing; and
5. (e) The circumstances under which medical assistance is provided during the pendency of a hearing.

10908.4 A timely notice of an adverse action shall be issued (based on the postmark for physical mail or time stamp for electronic submissions) at least fifteen (15) calendar days before the date an adverse action would become effective, except as permitted under §§ 10908.5 and 10908.7.

10908.5 The Department is not required to provide at least fifteen (15) calendar days' notice before the date an adverse action would become effective, but shall send adequate notice (as described in § 10908.3), under the following circumstances:

(a) The Department has factual information confirming the death of a beneficiary;

(b) The Department receives a documented and signed statement from a beneficiary:

(1) Stating that medical assistance is no longer required; or

(2) Providing information which requires termination or reduction of medical assistance and indicating that a beneficiary understands the consequence of supplying the information;

(c) A beneficiary's whereabouts are unknown and the Department mailings, directed to the beneficiary, have been returned by the post office indicating no known forwarding address; or

(d) A beneficiary has been deemed eligible for a medical assistance program, including Medicaid or CHIP, in another state and that fact has been verified.

10908.6 Under the circumstances identified in § 10908.5, the Department shall issue a notice no later than the effective date of the adverse action.

10908.7 Notwithstanding the fifteen (15)-day notice requirement set forth in § 10908.5, the Department shall not be required to issue a notice more than five (5) calendar days before the effective date of an adverse action if the Department the adverse action is based on facts indicating possible fraud by the beneficiary and those facts have been verified, if possible, through secondary sources.

10908.8 The Department shall grant a fair hearing when:

(a) An application for medical assistance in FCEP CHIP is denied;

(b) Eligibility for medical assistance under FCEP CHIP is suspended;

(c) Eligibility for medical assistance under FCEP CHIP is terminated;

(d) An applicant or beneficiary believes the Department has taken an action that affects the receipt, termination, amount, kind, or conditions of medical assistance in error; or

(e) A beneficiary was denied coverage of, or payment for, medical services;

(f) A beneficiary is dissatisfied with the District's determination that disenrollment from an MCO is appropriate; or

(g) A claim was denied or not acted upon with reasonable promptness pursuant to D.C. Official Code § 4-210.02(a).

10908.9 The Department shall not grant a hearing if the sole issue is a federal or District law requiring an automatic change that adversely affects some or all beneficiaries.

10908.10 The Department may deny or dismiss a request for a fair hearing if:

(a) The applicant or beneficiary withdraws the request in writing; or

(b) The applicant or beneficiary fails to appear at a scheduled hearing without good cause.

10908.11 An individual, an adult who is in the individual's household, or an authorized representative shall submit a fair hearing request via:

(a) Telephone;

(b) Mail;

(c) In person; or

(d) Through other commonly available electronic means.

10908.12 An applicant or beneficiary seeking a fair hearing shall submit a fair hearing request no later than ninety (90) calendar days following the date the notice of adverse action is mailed.

10908.13 The Department shall automatically schedule an administrative review of an adverse action, to occur before the fair hearing, if the applicant or beneficiary requests a fair hearing. The scheduling of an administrative review shall not affect the individual's right to a subsequent fair hearing.

10908.14 Where the Department provides notice as required under §§ 10908.3 through 10908.7, and the beneficiary requests a fair hearing before the date of adverse action, the Department may not terminate or reduce services until a hearing decision is rendered unless it is determined at the hearing that the sole issue is one of Federal or District law or policy.

10908.15 Reinstated services shall continue until a hearing decision is reached unless it is determined at the hearing that the sole issue is one of federal or District law or policy.

10908.16 The Department shall reinstate and continue services until a decision is rendered after a hearing if:

(a) Action is taken without the advance notice required under §§ 10908.5 through 10908.7;

(b) The beneficiary requests a hearing within ten (10) calendar days after the date that the beneficiary receives the notice of the adverse action. The date on which the notice is received is considered to be five (5) calendar days after the date on the notice, unless the beneficiary shows that notice was not received within the five (5) day period; or

(c) The Department determines that the action resulted from other than the application of federal or District law or policy.

10908.17 If a beneficiary's whereabouts are determined to be unknown, discontinued services shall be reinstated if the beneficiary's whereabouts become known during the time the beneficiary is eligible for services.

10908.18 Fair hearings and appeals for the District's FCEP CHIP shall be administered through the Office of Administrative Hearings (OAH) in accordance with DC Official Code § 4-210.01 et seq., and 1 DCMR § 2970 through 1 DCMR § 2978.

SOURCE: Final Rulemaking published at 72 DCR 013183 (November 28, 2025).