Medicaid Appeals and Litigation

When a Medicaid application has been denied or Medicaid eligibility has been terminated, there is an appeal process known as an Administrative Appeal. The appeal process is initiated by the filing of a request for a “State Hearing’ within 90 days of the denial or termination. 

State Hearing

This process is controlled by the Department of Job and Family Services and is not a fair and impartial hearing process. The Hearing Officers are employed by the State Department of Job and Family Services, are trained by the State Department of Job and Family Services and are promoted, demoted or fired by the same agency.  The agency now requires that every decision be signed by the Hearing Officer’s supervisor to be sure that the decisions are “appropriate”. In circumstances where a county caseworker has made an obvious error contradictory to the State’s policies and procedures, the Hearing Authority regularly overturns denials. When there is a question as to the State’s policy, a question between the policy and the actual rules incorporated by the State, or constitutional issues, the Hearing Authority rarely issues decisions in favor of the applicant.  Despite the unfairness of the process, it is an expedited process and is necessary for purposes of continuing the appeal process.

The State Hearing is the “trial portion” of the procedure, and as such, all appropriate evidence and issues of law must be raised at that hearing.  If you fail to properly pursue the State Hearing process and do not address each and every issue and fail to introduce all the necessary evidence, you are not permitted to supplement the record with additional evidence or incorporate or include any other legal arguments at the next level of appeal.  We regularly decline representation in cases where the State Hearing has already been completed if the record of the State Hearing is insufficient.  At the State Hearing, the focus will be upon the value or the type of assets.  Other factors, such as cost of care or intentions of the party, may also be of interest at this level.  The primary witnesses at these hearings are usually either the applicants or the caseworker and the caseworker’s supervisor.

The balance of the State Hearing process usually involves testimony of the County officials relating to the State’s policy and their adherence to the State Policy. This produces the record which will allow for a reversal or a remand of the denial/termination.

Administrative Appeal

Assuming that one has been unsuccessful at a State Hearing, and the appropriate record has been established at the State Hearing, the second level of appeal is knows as the “Administrative Appeal”, a briefing system whereby the errors of the State Hearing Authority, either from findings of fact or findings of law, are challenged with a brief. Again, all issues must be raised at this level, and as with the State Hearing process, this process is controlled by the Department of Job and Family Services. This step is necessary in order to maintain or to pursue further appeals.

Court Appeal

The third step in this process is an appeal to the Common Pleas Court in the county where benefits were denied/terminated. The primary benefit of this step is that for the first time, the denial/termination is being appealed to an unbiased decision maker. Common Pleas Court judges are not employed, trained, or in any way connected with the Department of Job and Family Services.  Further, the State’s interests are no longer in the hands of the county officials as an Assistant Attorney General is appointed to represent the State’s position. As the case is considered on appeal, the State Hearing record, either in the form of a transcript or in the form of stipulations, as well as all of the documents filed, are the record for appeal. No additional evidence is permitted at this time. The Court will consider the issues raised and considered in the State Hearing process and also those issues raised at the State Hearing that were not addressed by the Hearing Authority.  In order for the Court to make a determination, this process involves a close review of the State Hearing record and decision as well as a detailed briefing as to the facts and law.  While some judges are likely to give great weight to the agency process, most judges will consider the underlying fairness or unfairness of the process. For example, within some state agencies, independent Hearing Officers who are not employed by the agency are often used.  This does not hold true for the Department of Job and Family Services as the Hearing Officers they utilize are employed by the Department of Job and Family Services.   After the case has been briefed and after oral arguments are considered by the Common Pleas judge, that judge then issues a decision based upon the facts and law as set forth in the record and as argued in the briefs.  It has been our experience that Common Pleas Court judges around the State of Ohio are of very high quality and we have generally been pleased with the effort and rationale employed by the Common Pleas Court judges around the state.

In creating cases where precedent is important, the State has appealed most Common Pleas Court decisions in an effort to protect the precedent or the State policies.  Again, it has been our experience that the Court of Appeals judges are of exceptional quality and consider the constitutional issues as well as the substantive issues. Particularly in issues involving constitutional deficiencies in the process, it has also been our experience that the Court of Appeals judges are very capable of considering difficult constitutional issues.

Though very few cases are actually appealed to the Ohio Supreme Court, those appeals have usually been initiated by the State after we have been successful in a Court of Appeals. Although the Supreme Court is an elected Court, it has been our experience that the court is of very high quality and considers issues of Administrative Appeals very carefully before issuing decisions.

In the alternative, actions may be pursued in the U.S. District Court. The U.S. District Court judges are very capable, but we have found that the U.S. 6th Circuit Court of Appeals is perhaps the most pro-State court in the country. Therefore, we have avoided the 6th Circuit Court whenever possible. It is simply not a good court for the elderly, disabled or the poor. That Court has a good reputation regarding civil actions between differing parties, including insurance companies, but it is known to be a very “pro-State’s rights” court.

The expense of litigation through the Administrative Appeal process is typically less expensive than civil litigation through the Common Pleas Courts. We have been able to keep the cost of litigation to a minimum by avoiding expensive discovery, such as depositions, and by avoiding the many motions that stymies civil litigation. This approach also focuses the case upon the actual findings of the caseworker rather than upon the truthfulness of the applicant.  In most of these cases, the focus of the litigation is issues of law rather than issues of facts, and while they are intellectually more challenging for the attorneys.  By their very nature, they are better for the client, both fiscally and emotionally.