4202 APPEAL RIGHTS FOR APPLICANTS/BENEFICIARIES

4202.1 An applicant or beneficiary shall receive advance notice and shall have the opportunity to request a fair hearing if:

1. (a) They are found ineligible for participation in the EPD Waiver based on the criteria set forth in Subsection 4201.2;
2. (b) They are not given the choice between EPD Waiver services or institutional care;
3. (c) They are denied the choice of service(s) from a qualified and willing provider in accordance with 42 CFR § 431.51; or
4. (d) DHCF or its designee takes action to deny, suspend, reduce, or terminate services, or disenroll the beneficiary or applicant from the EPD Waiver program.

4202.2 An EPD Waiver provider shall issue a written notice in cases of intended actions to deny, discharge, suspend, transfer, or terminate services for any applicant or beneficiary. Except as set forth in Subsections 4202.3 and 4205.11, the notice shall be issued at least thirty (30) calendar days prior to the effective date of the proposed action and shall include the following information:

1. (a) The intended action;
2. (b) The reason(s) for the intended action;
3. (c) Citations to the law(s) and regulations supporting the intended action;
4. (d) A list of EPD Waiver standards supporting the intended action;
5. (e) An explanation of the applicant or beneficiary's right to request a hearing;
6. (f) The circumstances under which the applicant or beneficiary's current level of services will be continued if a hearing is requested; and
7. (g) A copy of the directory of other EPD Waiver providers.

4202.3 An EPD Waiver provider shall issue written notice when the intended action is discharge of a beneficiary based on the beneficiary's failure to meet eligibility criteria set forth in Subsection 4201.2. The notice shall be issued at least seven (7) calendar days prior to the effective date of the proposed action, or longer if required

by applicable D.C. Health regulations, and shall include the following information:

(a) The intended action;

(b) The reason(s) for the intended action;

(c) Citations to the law(s) and regulations supporting the intended action;

(d) A list of EPD Waiver standards supporting the intended action; and

(e) An explanation that the beneficiary will receive a separate notice from DHCF or its designee informing the beneficiary of the termination of EPD Waiver eligibility, disenrollment from the Waiver program, and the right to appeal these actions.

4202.4 DHCF or its designee shall issue a written notice in cases where it intends to take action to deny, discharge, suspend, or reduce Waiver services, or disenroll applicants or beneficiaries from the EPD Waiver program. The notice shall be issued at least thirty (30) calendar days prior to the effective date of the proposed action and shall include the following information:

(a) The intended action;

(b) The reason(s) for the intended action;

(c) Citations to the law(s) and regulations supporting the intended action;

(d) An explanation of the individual's right to request a hearing; and

(e) The circumstances under which the individual's current level of services will be continued if a hearing is requested.

SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017); as amended by Final Rulemaking published at 72 DCR 004996 (April 25, 2025).