Burden of Proof in Medicaid Hearings

Executive Summary

In this fact sheet, we discuss the burden of proof that Medicaid applicants and beneficiaries bear when seeking eligibility and coverage for necessary services. We will focus on this issue as it arises in connection with administrative hearings.
Individuals seeking Medicaid benefits must apply for eligibility. Once eligibility is determined, medical services may be covered for beneficiaries. If an individual is denied eligibility, or if coverage for services are denied, individuals may request an administrative 
hearing to contest these determinations. In other circumstances, individuals who are already receiving benefits may have their eligibility terminated or benefits are terminated . Because the Medicaid statute and regulations do not address the issue, questions may arise regarding the burden of proof in these circumstances. 
 
A. Sources to Consult
 
The Medicaid program is a cooperative federal-state partnership and its basic requirements are governed by federal law. 2 The statute discusses administrative hearings in a single sentence, requiring that state Medicaid plans ?provide for granting an opportunity for a fair hearing before the State agency to any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness.?3 Regulations flesh out this requirement. Among other things, if a state Medicaid agency intends to take action that is adverse to an individual, he or she must receive written notice of the intended action that is both adequate and timely.4 An adverse action is a termination, suspension or reduction of Medicaid eligibility or covered services.5 If requested, an administrative hearing must be conducted at a reasonable time, date and place by an impartial hearing official.6 At the hearing, the applicant or recipient must be allowed to present witnesses, establish facts, present argument and crossexamine adverse witnesses.7 The burden of proof at the hearing is not addressed. 
Because the statute and regulations are silent on the point, claimants and their advocates must look elsewhere to determine who bears the burden of proof. First, a number of federal and state decisions address the issue. Moreover, every state and the District of Columbia have Administrative Procedure Acts (APAs) that govern the conduct of administrative hearings. With only a few exceptions, such as Virginia, state laws require the Medicaid agency to comply with APA requirements.9 Thus, advocates should first review their state?s APA to determine whether it addresses the burden of proof. Several that do are discussed below. Legal authority for the administrative burden of proof might also be found in state common law. In addition, Medicaid fair hearing decisions are required by law to be available to the public.10 Accordingly, advocates should be able to obtain them and review the Medicaid decisions that administrative law judges in their states have issued to see whether they discuss the burden of proof. These sources are discussed more fully below. 

B. Burden when Eligibility for Benefits is at Issue
To be eligible for Medicaid, individuals must apply and meet financial, citizenship and residency requirements. When an individual appeals action of a state Medicaid agency, the burden of proof depends on whether the issue is the initial eligibility of an applicant or whether the eligibility of a current beneficiary will be terminated. 
Generally speaking, the burden is placed upon the party who is attempting to change the status quo. Accordingly, those applying for eligibility usually bear the burden of proof, while the state Medicaid agency generally bears this burden when attempting to terminate eligibility. Some courts characterize this issue in terms of ?presumptions.? For example, there may be a presumption that a person who quit a job did so to qualify for Medicaid benefits. In that case, that person would have the burden of proof to show that he did not quit for that reason.11Illustrations of these principles follow. 
 

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