C.F.R. » Title 42 » CHAPTER IV—CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES › SUBCHAPTER C—MEDICAL ASSISTANCE PROGRAMS › PART 431—STATE ORGANIZATION AND GENERAL ADMINISTRATION › Subpart E—Fair Hearings for Applicants and Beneficiaries

42 C.F.R. § 431.201

Definitions

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For purposes of this subpart:

Action means one of the following:

(1) A termination, suspension of, or reduction in covered benefits or services, including benefits or services for which there is a current approved prior authorization;

(2) A termination, suspension of, or reduction in Medicaid eligibility, or an increase in beneficiary liability, including a determination that a beneficiary must incur a greater amount of medical expenses to establish income eligibility in accordance with § 435.121(e)(4) or § 435.831 of this chapter;

(3) A determination that a beneficiary is subject to an increase in premiums or cost-sharing charges under subpart A of part 447 of this chapter; or

(4) A determination by a skilled nursing facility or nursing facility to transfer or discharge a resident and an adverse determination by a State regarding the preadmission screening and resident review requirements of section 1919(e)(7) of the Act.

Adverse determination means a determination made in accordance with sections 1919(b)(3)(F) or 1919(e)(7)(B) of the Act that the individual does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services.

Date of action means the intended date on which a termination, suspension, reduction, transfer or discharge becomes effective. It also means the date of the determination made by a State with regard to the preadmission screening and annual resident review requirements of section 1919(e)(7) of the Act.

De novo hearing means a hearing that starts over from the beginning.

Evidentiary hearing means a hearing conducted so that evidence may be presented.

Joint fair hearing request means a request for a Medicaid fair hearing which is included in an appeal request submitted to an Exchange or Exchange appeals entity under 45 CFR 155.520 or other insurance affordability program or appeals entity, in accordance with the signed agreement between the agency and an Exchange or Exchange appeals entity or other program or appeals entity described in § 435.1200(b)(3) of this chapter .

Local evidentiary hearing means a hearing held on the local or county level serving a specified portion of the State.

Notice means a written statement that meets the requirements of § 431.210.

Request for a hearing means a clear expression by the applicant or beneficiary, or his authorized representative, that he wants the opportunity to present his case to a reviewing authority.

Send means deliver by mail or in electronic format consistent with § 435.918 of this chapter.

Service authorization request means a managed care enrollee's request for the provision of a service.

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 67 FR 41095, June 14, 2002; 78 FR 42301, July 15, 2013; 81 FR 86448, Nov. 30, 2016; 89 FR 8980, Feb. 8, 2024]
Notes of Decisions
Cited in 41 cases (6 in the last 5 years), 1984–2026 · leading case: Prunckun v. Delaware Dept. of Health & Soc. Servs. Oldham v. Delaware Dept. of Health & Soc. Servs., 201 A.3d 525 (Del. 2019).
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Prunckun v. Delaware Dept. of Health & Soc. Servs. Oldham v. Delaware Dept. of Health & Soc. Servs., 201 A.3d 525 (Del. 2019). · cites it 3× “200(b), 42 C.F.R. 431.201 and 16 Del. Admin. C. § 5100(1), ruled that a Fair Hearing was required under the applicable regulations.”
K.W. Ex Rel. D.W. v. Armstrong, 789 F.3d 962 (9th Cir. 2015). · cites it 2× “Compare 42 C.F.R. §§ 431.201 , 431.206(c)(2), with Am.”
Marquez v. State Dep't of Health Care Servs., 240 Cal. App. 4th 87 (Cal. Ct. App. 2015). · cites it 2× “application for or receipt of the aid or other service” (italics added)]; see also 42 C.F.R. §431.201 (2014) [“action” means termination, suspension, or reduction of eligibility or covered services]; 42 U.”
Grier v. Goetz, 402 F. Supp. 2d 876 (M.D. Tenn. 2005). · cites it 3× “” 42 C.F.R. § 431.201 . The 2003 Consent Decree defines termination, suspension or reduction to include “acts or omissions on the part of the state defendants or others acting on their behalf which result in the interruption of a course of necessary clinical treatment for a…”
Washington v. DeBeaugrine, 658 F. Supp. 2d 1332 (N.D. Fla. 2009). “” 42 C.F.R. § 431.201 . A wavier-program beneficiary may also have a right to a hearing under Florida law.”
Lisnitzer v. Zucker, 983 F.3d 578 (2d Cir. 2020). “” See 42 C.F.R. § 431.201 (definitions). As we said earlier, 18 to determine its meaning, we look to our prior cases; to the structure and 14 1 purpose of the regulations, helped by a reading offered by the United States; and 2 to the State Medicaid Manual, to which we owe some…”
Granato v. Bane, 74 F.3d 406 (2d Cir. 1996). · cites it 5× “PARKER, Circuit Judge: The issue in this consolidated appeal is whether New York State’s termination of Medicaid home care services upon a recipient’s admission to a hospital constitutes an “action” under 42 C.F.R. § 431.201 (1994), thereby triggering the recipient’s right to…”
Ladd v. Thomas, 962 F. Supp. 284 (D. Conn. 1997). · cites it 2× “” 42 C.F.R. § 431.201 . Under federal law, notice means “a written statement that meets the requirements of § 431.”
M.A. ex rel. Avila v. Norwood, 133 F. Supp. 3d 1093 (N.D. Ill. 2015). · cites it 2× “2015) (citing 42 C.F.R. § 431.201 ). . In pertinent part, § 431.”
Mitchell ex rel. Mitchell v. Cmty. Mental Health of Cent. Michigan, 243 F. Supp. 3d 822 (E.D. Mich. 2017). “§§ 431.213, 431.214. The notice must say what action the State is taking, 42 C.”
Haymons v. Williams, 795 F. Supp. 1511 (M.D. Fla. 1992). · cites it 2× “or reduction of Medicaid eligibility or covered services” under 42 C.F.R. § 431.201 for which advance notice and the opportunity for a pretermin-ation hearing must be given.”
In Re Easly, 771 A.2d 844 (Pa. Commw. Ct. 2001). · cites it 2× “" 42 C.F.R. § 431.201 . See also King v. Sullivan, 776 F.”
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