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. § 431.220

When a hearing is required

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(a) The State agency must grant an opportunity for a hearing to the following:

(1) Any individual who requests it because he or she believes the agency has taken an action erroneously, denied his or her claim for eligibility or for covered benefits or services, or issued a determination of an individual's liability, or has not acted upon the claim with reasonable promptness including, if applicable—

(i) An initial or subsequent decision regarding eligibility;

(ii) A determination of the amount of medical expenses that an individual must incur in order to establish eligibility in accordance with § 435.121(e)(4) or § 435.831 of this chapter; or

(iii) A determination of the amount of premiums and cost sharing charges under subpart A of part 447 of this chapter;

(iv) A change in the amount or type of benefits or services;

(v) A request for exemption from mandatory enrollment in an Alternative Benefit Plan; or

(vi) A prior authorization decision.

(2) Any resident who requests it because he or she believes a skilled nursing facility or nursing facility has erroneously determined that he or she must be transferred or discharged.

(3) Any individual who requests it because he or she believes the State has made an erroneous determination with regard to the preadmission and annual resident review requirements of section 1919(e)(7) of the Act.

(4) Any MCO, PIHP, or PAHP enrollee who is entitled to a hearing under subpart F of part 438 of this chapter.

(5) Any enrollee in a non-emergency medical transportation PAHP (as that term is defined in § 438.9 of this chapter) who has an action as stated in this subpart.

(6) Any enrollee who is entitled to a hearing under subpart B of part 438 of this chapter.

(b) The agency need not grant a hearing if the sole issue is a Federal or State law requiring an automatic change adversely affecting some or all beneficiaries.

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 67 FR 41095, June 14, 2002; 67 FR 65505, Oct. 25, 2002; 81 FR 27853, May 6, 2016; 81 FR 86448, Nov. 30, 2016; 89 FR 8980, Apr. 8, 2024]
Notes of Decisions
Cited in 94 cases (17 in the last 5 years), 1979–2026 · leading case: Melissa Wilson v. Darin Gordon
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Melissa Wilson v. Darin Gordon (2016) ca6 · cites it 2× “§ 1396a(a)(3); 42 C.F.R. § 431.220 (a)(1) (“The State agency must grant an No.”
Soskin v. Reinertson (2004) ca10 · cites it 3× “” Additionally, one of the implementing regulations, 42 C.F.R. § 431.220 , directly addresses when hearings are required; it states: When a hearing is required.”
NB Ex Rel. Peacock v. District of Columbia (2015) cadc · cites it 3× “” 42 C.F.R. § 431.220 (a)(l)-(2). The regulations also specify circumstances in which notice of the right to a hearing must be provided, as well as the content of that notice.”
Bellin v. Zucker (2021) ca2 “42 C.F.R. § 431.220 (a)(1). Bellin argues that RiverSpring “denied .”
Washington v. DeBeaugrine (2009) flnd · cites it 3× “” Under 42 C.F.R. § 431.220 , a state agency must “grant an opportunity for a hearing to .”
Prunckun v. Delaware Dept. of Health & Social Services Oldham v. Delaware Dept. of Health & Social Services (2019) del · cites it 3× “There is some tension in the rules as 42 C.F. R. § 431.220 (b) states that "[t]he agency need not grant a hearing if the sole issue is a Federal or State law requiring an automatic change adversely affecting some or all beneficiaries.”
Doe v. Kidd (2007) ca4 · cites it 2× “" (emphasis added)); 42 C.F.R. §§ 431.220 ,-.241 (providing for a fair hearing on the request of an aggrieved Medicaid recipient).”
Joseph S. v. Hogan (2008) nyed · cites it 2× “§ 1396r(e)(7)(F); 42 C.F.R. § 431.220 ). 22 However, these review procedures have been held not to constitute a comprehensive remedial scheme sufficient to supplant § 1983.”
Grier v. Goetz (2005) tnmd · cites it 5× “See 42 C.F.R. § 431.220 (a)(1) (requiring the State to grant an opportunity for a hearing to “[a]ny applicant who requests it because his claim for services is .”
Rosen v. Tennessee Commissioner of Finance & Administration (2002) tnmd · cites it 5× “42 C.F.R. § 431.220 (a). 42 C.F.R. § 431.”
In Re Easly (2001) pacommwct · cites it 6× “The Secretary argues that changes in location of care of an ICF/MR resident do not trigger any right to a hearing pursuant to federal regulations, 42 C.F.R. § 431.220 (a). [14] The Secretary argues that because there was no change in Ms.”
Conlan v. Bonta' (2002) calctapp “) Thus, the failure of the Department to provide a method by which recipients may be promptly reimbursed for covered medical expenses for which they paid during the retroactivity period violates federal law.”
Show all 94 citing cases →
— 42 C.F.R. § 431.220(a) — 1 case
Law v. N.M. Human Servs. Dep’t (2019) nmctapp
— 42 C.F.R. § 431.220(a)(1) — 3 cases
Murphy v. Minnesota Department of Human Services (2019) mnd
Law v. N.M. Human Servs. Dep’t (2019) nmctapp
Schreur v. Department of Human Services (2010) michctapp
— 42 C.F.R. § 431.220(a)(2) — 1 case
J.W. v. Agency for Health Care Administration (2015) fladistctapp
— 42 C.F.R. § 431.220(b) — 1 case
Harriman v. Department of Children & Families (2004) fladistctapp
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