Produced by Sarah Somers and Celine Lefebvre
Q: I am representing a client at a Medicaid administrative hearing who has been denied eligibility for Medicaid. Does federal Medicaid law indicate whether she bears the burden of proof?
A: The Medicaid statute and regulations do not address burden of proof, with the exception of a requirement related to transfers of
assets. Cases and some state laws do discuss the issue and the burden of proof generally rests on the party seeking to change the status quo.
Discussion
If an individual is denied eligibility for Medicaid or if coverage for Medicaid services is denied or reduced, she may request an administrative hearing to contest these determinations. Individuals who are already receiving benefits may have their eligibility or services terminated. Because the Medicaid statute and regulations do not address the issue, questions may arise regarding the burden of proof.3
The Medicaid statute requires 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.?4 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.5 An adverse action is a termination, suspension or reduction of Medicaid eligibility or covered services.6 Administrative hearings must be conducted at a reasonable time, date and place by an impartial hearing official.7 At the hearing, the applicant or recipient must be allowed to present witnesses, establish facts, present argument and crossexamine adverse witnesses.8 The burden of proof at the hearing is not addressed.
A number of federal and state decisions address the issue.9 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.10 Legal authority for the administrative burden of proof might also be found in state common law. These sources are discussed more fully below.
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