Understanding Medicaid Fair Hearings in Florida

Advocacy 101
Preparing for Your Medicaid
Fair Hearing Before the
Office of Fair Hearings or
Office of Appeal Hearings
Rachel Siegel-McLaughlin,
Senior Staff Attorney
Jatinique Randle, Staff Attorney
June 08,2019
Disability Rights Florida
Funding, responsibility, and authority under nine
federal programs to protect the rights of Floridians with
disabilities.
A not-for-profit corporation since 1987.
Offices in Tallahassee, Tampa, Gainesville and
Hollywood.
Satellite offices in several other communities.
Our Mission
To advance the quality of life, dignity, equality,
self determination, and freedom of choice of
persons with disabilities through collaboration,
education, advocacy, as well as legal and
legislative strategies.
Agenda
Introduction to Advocacy 101
What is the Office of Fair Hearings?
What is the Office of Appeal Hearings?
Notices and Requesting a Fair Hearing
Preparing for Your Hearing
Questions
Advocacy 101
Disability Rights Florida’s Advocacy 101 is a manual designed to assist
individual in preparing for a Medicaid case before:
Florida Division of Administrative Hearings (DOAH)
The Florida Office of Fair Hearings (OFH)
The Florida Office of Appeal Hearings (OAH)
Today’s Presentation will focus on OFH and OAH
Available Online at:
http://www.disabilityrightsflorida.org/resources/disability_topics
The Office of Fair Hearings
https://flmedicaidmanagedcare.com/home/medicaidfairhearing
The Office of Fair Hearings (OFH) is part of the Agency for
Health Care Administration.
OFH employs hearing officers who conduct hearings in cases
affecting fee-for-service and managed care recipients.
Office of Fair Hearings Contact Information
OFH’s contact information for 
Requesting a Medicaid Fair Hearing 
from AHCA is:
 
Agency for Healthcare Administration Medicaid Hearing Unit
 
P.O. Box 60127 Ft. Meyers, FL 33906
 
Telephone: (877) 254-1055
 
Fax: (239) 338-2642
 
Email: MedicaidHearingUnit@ahca.myflorida.com
OFH’s contact information for 
Obtaining Information from AHCA 
Regarding a Medicaid
Fair Hearing Request is:
 
Agency for Healthcare Administration Office of Fair Hearings
 
2727 Mahan Drive, MS#11 Tallahassee, FL 32308
 
Telephone: (850) 412-3649
 
Fax: (850) 487-1423
 
Email: OfficeofFairHearings@ahca.myflorida.com
The Office of Appeal Hearings
https://www.myflfamilies.com/about-us/office-inspector-general/appeal-
hearings/
The Office of Appeal Hearings (OAH) is part of the Florida Department of
Children and Families’ Office of Inspector General.
OAH employs full-time hearing officers who conduct hearings in cases
where a state agency, such as the Agency for Persons with Disabilities
(APD) or the Department of Children and Families (DCF), makes a decision
which unfavorably affects a person’s rights or benefits.
Office of Appeal Hearings Contact Information
Contact information for the Office of Appeal Hearings:
     Department of Children and Families, Office of Appeal Hearings
     1317 Winewood Blvd, Bldg. 5, Room 255
     Tallahassee, Florida 32399
     Telephone: (850) 488-1429
     Fax: (850) 487-0662
     Email: 
appeal.hearings@myflfamilies.com
Notices
AHCA, APD, Managed Care Companies, and others must send you a
written
 notice whenever they deny, reduce, or terminate your request for
supports or services
Verbal notice is not enough, do not accept verbal or other informal notice
If you do not receive written notice, request it as soon as possible
Look for these three things:
1.
What is being 
denied or reduced
?
2.
What is the 
justification
 for the denial/reduction?
3.
What are your 
appeal rights 
and instructions?
Formats change, but content does not
10
Requesting an Appeal
Follow the instructions in the Notice
The deadline for requesting an appeal varies depending on the Agency, but
it should be clearly stated on the Notice you receive
Be sure to make it clear if you wish to continue to receive services pending
the outcome of your appeal
Make 
a written request 
for the appeal if possible, and save a dated copy
of this request
11
Words to Know
Petitioner
: The person requesting an appeal, the person who’s services are
being reduced or denied
Respondent
: The Agency or organization that has reduced or denied
petitioner’s services
Exhibit
: A piece or set of evidence in a hearing, usually a document
Hearing Officer
: The presiding officer or “judge” at your hearing
Burden of Proof
: The responsibility of a specific party to use the evidence
to prove to the court what the party believes the outcome should be. Must
be proven by the “preponderance of the evidence” or more likely than not.
12
5 Steps of Preparation
You should get a letter from OFH or OAH stating when and where the
hearing will be held
5 steps:
1.
Research the laws and rules that affect your care – many can be found online,
including some links provided in the Advocacy 101 manual
2.
Write your arguments
3.
Gather evidence and witnesses to support those arguments
4.
Prepare your testimony
5.
Request information from the Agency through the “Discovery” process
If you need more time to prepare, you can request a “continuance” from
the hearing officer, submit your request in writing.
13
The Hearing Itself
The hearing will be telephonic for OFH
The hearing can be telephonic or in-person (at your request) for
OAH
The hearing officer, the Petitioner’s party, Agency area staff and
potentially an Agency attorney will be present
Try to approach the hearing and your arguments from a logical
and rational, not emotional, standpoint
Let the Hearing Officer guide the proceedings, but do not be
afraid to speak up
14
How to Prove Your Case
You have to know the law, you cannot rely only on a sense of
fairness or unproven “need”
You need to know who has the burden of proof
You should assert facts that you can prove
Avoid generic or summary language
Respond directly to the agency’s arguments
Listen carefully and take notes
15
What Happens Next?
There will not be an immediate response from the Hearing
Officer
After a few weeks you will receive a written decision from the
Hearing Officer, called a 
final order
Read the final order carefully to determine what has been
affirmed and/or what has been denied.
16
Appeals
An appeal must be filed within 30 days of the Final Order
You may file in either the 1st District Court of Appeals or the
District of your residency
Appeals must be based on legal issues, not factual issues and
ONLY on issues raised during the hearing
Clerk of Courts are a valuable resource
17
Requesting Accommodations
Contact OAH or OFH by phone or email to request an
accommodation for your hearing.
You should make this request as early as possible and at least 7
days prior to your hearing date.
18
Jay has received a notice in the mail
about a termination of his services.
What should he look for in the notice?
Jay has received a “Notice of Adverse Benefit
Determination” in the mail from his Medicaid
Managed Care Company regarding a reduction
of his services. What are his next steps in
requesting to appeal the action taken in the
notice?
What does “burden on proof” mean?
Questions?
Contact Us:
2473 Care Drive, Suite 200
Tallahassee, Florida 32308
800.342.0823 • TDD 800.346.4127
www.DisabilityRightsFlorida.org
Slide Note

Expertise

Rachel Siegel-McLaughlin is a Senior Staff Attorney at Disability Rights Florida and has worked at Disability Rights Florida for over six years. While at Disability Rights Florida, she has worked as both an advocate and an attorney on a number of Medicaid Waiver appeal cases. Attorney Siegel-McLaughlin has assisted individuals with a variety of issues including: denials of Medicaid Waiver eligibility, denials of crisis applications for Waiver Services, denials of significant additional needs funding requests, and cost plan or service reductions. She has also provided numerous individuals with technical assistance and self-advocacy support during all parts of the APD application and appeal process. 

Jatinique Randle has been a staff attorney with Disability Rights Florida since 2017. She has assisted individuals in administrative hearings pertaining to adverse Medicaid waiver decisions, has worked to provide assistance to individuals who have faced barriers in receiving accommodations under state and federal laws, has advocated for the enforcement of voting rights for individuals with disabilities, and has conducted investigations into allegations of abuse and neglect in institutions and similar facilities.

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Learn about preparing for your Medicaid fair hearing in Florida before the Office of Fair Hearings or Office of Appeal Hearings. Explore the role of Disability Rights Florida in advocating for the rights of individuals with disabilities and discover key information about the process, contact details, and resources available for assistance.


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  1. Advocacy 101 Preparing for Your Medicaid Fair Hearing Before the Office of Fair Hearings or Office of Appeal Hearings Rachel Siegel-McLaughlin, Senior Staff Attorney Jatinique Randle, Staff Attorney June 08,2019

  2. Disability Rights Florida Funding, responsibility, and authority under nine federal programs to protect the rights of Floridians with disabilities. A not-for-profit corporation since 1987. Offices in Tallahassee, Tampa, Gainesville and Hollywood. Satellite offices in several other communities.

  3. Our Mission To advance the quality of life, dignity, equality, self determination, and freedom of choice of persons with disabilities through collaboration, education, advocacy, as well as legal and legislative strategies.

  4. Agenda Introduction to Advocacy 101 What is the Office of Fair Hearings? What is the Office of Appeal Hearings? Notices and Requesting a Fair Hearing Preparing for Your Hearing Questions

  5. Advocacy 101 Disability Rights Florida s Advocacy 101 is a manual designed to assist individual in preparing for a Medicaid case before: Florida Division of Administrative Hearings (DOAH) The Florida Office of Fair Hearings (OFH) The Florida Office of Appeal Hearings (OAH) Today s Presentation will focus on OFH and OAH Available Online at: http://www.disabilityrightsflorida.org/resources/disability_topics

  6. The Office of Fair Hearings https://flmedicaidmanagedcare.com/home/medicaidfairhearing The Office of Fair Hearings (OFH) is part of the Agency for Health Care Administration. OFH employs hearing officers who conduct hearings in cases affecting fee-for-service and managed care recipients.

  7. Office of Fair Hearings Contact Information OFH s contact information for Requesting a Medicaid Fair Hearing from AHCA is: Agency for Healthcare Administration Medicaid Hearing Unit P.O. Box 60127 Ft. Meyers, FL 33906 Telephone: (877) 254-1055 Fax: (239) 338-2642 Email: MedicaidHearingUnit@ahca.myflorida.com OFH s contact information for Obtaining Information from AHCA Regarding a Medicaid Fair Hearing Request is: Agency for Healthcare Administration Office of Fair Hearings 2727 Mahan Drive, MS#11 Tallahassee, FL 32308 Telephone: (850) 412-3649 Fax: (850) 487-1423 Email: OfficeofFairHearings@ahca.myflorida.com

  8. The Office of Appeal Hearings https://www.myflfamilies.com/about-us/office-inspector-general/appeal- hearings/ The Office of Appeal Hearings (OAH) is part of the Florida Department of Children and Families Office of Inspector General. OAH employs full-time hearing officers who conduct hearings in cases where a state agency, such as the Agency for Persons with Disabilities (APD) or the Department of Children and Families (DCF), makes a decision which unfavorably affects a person s rights or benefits.

  9. Office of Appeal Hearings Contact Information Contact information for the Office of Appeal Hearings: Department of Children and Families, Office of Appeal Hearings 1317 Winewood Blvd, Bldg. 5, Room 255 Tallahassee, Florida 32399 Telephone: (850) 488-1429 Fax: (850) 487-0662 Email: appeal.hearings@myflfamilies.com

  10. Notices AHCA, APD, Managed Care Companies, and others must send you a written notice whenever they deny, reduce, or terminate your request for supports or services Verbal notice is not enough, do not accept verbal or other informal notice If you do not receive written notice, request it as soon as possible Look for these three things: 1. What is being denied or reduced? 2. What is the justification for the denial/reduction? 3. What are your appeal rights and instructions? Formats change, but content does not 10

  11. Requesting an Appeal Follow the instructions in the Notice The deadline for requesting an appeal varies depending on the Agency, but it should be clearly stated on the Notice you receive Be sure to make it clear if you wish to continue to receive services pending the outcome of your appeal Make a written request for the appeal if possible, and save a dated copy of this request 11

  12. Words to Know Petitioner: The person requesting an appeal, the person who s services are being reduced or denied Respondent: The Agency or organization that has reduced or denied petitioner s services Exhibit: A piece or set of evidence in a hearing, usually a document Hearing Officer: The presiding officer or judge at your hearing Burden of Proof: The responsibility of a specific party to use the evidence to prove to the court what the party believes the outcome should be. Must be proven by the preponderance of the evidence or more likely than not. 12

  13. 5 Steps of Preparation You should get a letter from OFH or OAH stating when and where the hearing will be held 5 steps: 1. Research the laws and rules that affect your care many can be found online, including some links provided in the Advocacy 101 manual 2. Write your arguments 3. Gather evidence and witnesses to support those arguments 4. Prepare your testimony 5. Request information from the Agency through the Discovery process If you need more time to prepare, you can request a continuance from the hearing officer, submit your request in writing. 13

  14. The Hearing Itself The hearing will be telephonic for OFH The hearing can be telephonic or in-person (at your request) for OAH The hearing officer, the Petitioner s party, Agency area staff and potentially an Agency attorney will be present Try to approach the hearing and your arguments from a logical and rational, not emotional, standpoint Let the Hearing Officer guide the proceedings, but do not be afraid to speak up 14

  15. How to Prove Your Case You have to know the law, you cannot rely only on a sense of fairness or unproven need You need to know who has the burden of proof You should assert facts that you can prove Avoid generic or summary language Respond directly to the agency s arguments Listen carefully and take notes 15

  16. What Happens Next? There will not be an immediate response from the Hearing Officer After a few weeks you will receive a written decision from the Hearing Officer, called a final order Read the final order carefully to determine what has been affirmed and/or what has been denied. 16

  17. Appeals An appeal must be filed within 30 days of the Final Order You may file in either the 1st District Court of Appeals or the District of your residency Appeals must be based on legal issues, not factual issues and ONLY on issues raised during the hearing Clerk of Courts are a valuable resource 17

  18. Requesting Accommodations Contact OAH or OFH by phone or email to request an accommodation for your hearing. You should make this request as early as possible and at least 7 days prior to your hearing date. 18

  19. Jay has received a notice in the mail about a termination of his services. What should he look for in the notice?

  20. Jay has received a Notice of Adverse Benefit Determination in the mail from his Medicaid Managed Care Company regarding a reduction of his services. What are his next steps in requesting to appeal the action taken in the notice?

  21. What does burden on proof mean?

  22. Questions?

  23. Contact Us: 2473 Care Drive, Suite 200 Tallahassee, Florida 32308 800.342.0823 TDD 800.346.4127 www.DisabilityRightsFlorida.org

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