*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: June 1, 2011 |
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29.10.05 - Administrative Disqualification Hearings |
Archived: June 1, 2016 (Previous Versions) |
An Administrative Disqualification Hearing (ADH) is a formal, impartial review by a Hearing Judge to determine if an individual committed an Intentional Program Violation (IPV).
This section describes the Administrative Disqualification Hearing (ADH) process and fraud disqualification provisions. ADH and fraud disqualification apply only to MinnesotaCare adults without children.
Intentional Program Violation (IPV).
ADH Waivers and Request for ADH.
Intentional Program Violation (IPV)
Any of the following actions by an individual, whether or not eligibility or benefit levels are affected, are considered an IPV for purposes of establishing fraud in an ADH.
l Willfully or intentionally making a false or misleading statement.
l Misrepresenting, concealing or withholding facts.
l Misusing health care identification cards.
Not all instances of misrepresentation or failure to report timely constitute an IPV. There must be an intentional act of deception or one taken with an appreciation or understanding of its consequences or wrongfulness and must be proven by a clear and convincing legal standard of proof.
Initiate ADH for MinnesotaCare adults without children enrollees accused of committing an IPV when criminal charges are not being pursued. ADH procedures and requirements, except for the notice of hearing as explained below, are the same as for appeals.
Do not make concurrent referrals for prosecution and ADH. Do not refer IPVs that have already been resolved through the ADH process for criminal prosecution.
If an IPV referred for criminal prosecution is dismissed in court, the investigating agency may refer it for ADH. ADH uses the lower ”clear and convincing” test as opposed to the ”any reasonable doubt” standard required in a criminal prosecution.
ADH Waivers and Requests for ADH
After identifying an IPV and deciding to pursue ADH process rather than criminal prosecution, offer the accused person the opportunity to waive the appearance before a Hearing Judge and simply agree to the prescribed disqualification penalties.
The waiver allows the client to admit to the facts or not, with the understanding that the disqualification penalty will be imposed in either case.
l Do not offer waivers when there is only a suspicion of guilt but the evidence is not convincing.
l Do not threaten to pursue prosecution if the client fails to sign the waiver.
l Offer the waiver only when the agency has already determined that pursuing ADH is appropriate. The waiver is simply an opportunity to opt out of the actual hearing.
To request ADH and offer a waiver:
1. Complete the Notice of Intentional Program Violation Waiver of Administrative Disqualification Hearing (DHS-3131). Prepare a narrative summary of the allegations, investigative findings, and the evidence to support the findings.
2. Have a second party other than the assigned worker review and sign the form and find that the case facts, if proven, would justify a finding of fraud.
3. Give or send the ADH Waiver to the client. Include a list of legal aid offices. Allow 10 days for the client to return the form.
4. If the client returns the signed form waiving his/her right to a hearing, disqualify the person for the appropriate length of time. See fraud disqualification.
Clients may revoke the signed waiver in writing and request an ADH. The written revocation must be received by the earlier of
n The effective date of the proposed disqualification, or
n 30 days from the date the waiver was signed
5. If the client:
n Refuses to sign the waiver, or
n Requests a hearing, or
n Fails to return the waiver within 10 days,
complete the Request for Administrative Disqualification Hearing (DHS-3132) and send to:
Minnesota Department of Human Services.
Appeals Office.
P.O. Box 64941.
St. Paul, MN 55164-0941.
Upon receipt of the DHS-3132, the Office of Appeals will either accept or deny the request. If denied, the agency will receive a notice indicating the reason for the denial. Denied requests may be resubmitted to the Office of Appeals for reevaluation.
If the Office of Appeals accepts a request it will
l schedule a hearing date.
l send the client and agency a notice of hearing. The notice will include a copy of the summary prepared by the agency.
Federal regulations require the Office of Appeals to give notice of an ADH hearing at least 30 days in advance (unless the client waives the hearing), rather than the five-day notice for a regular fair hearing. ADH requests may be withdrawn anytime before the scheduled hearing date with written notice to both the client and the Office of Appeals.
A judge may combine a fair hearing and ADH into a single hearing if the factual issues arise out of the same or related circumstances.
l The client must receive 30 days advance notice (unless waived) that the hearings will be combined.
l The Office of Appeals must conduct the hearing, reach a decision, and notify the client and agency of the decision within 90 days of client notification of an ADH or a combined hearing.
ADH procedures do not include the opportunity to request a reconsideration of the decision by the Appeals Office. A party who disagrees with the Judge’s decision may start an appeal in district court within 30 days of the date of the decision.
Disqualify people found guilty of fraud by an ADH decision. See fraud disqualification.
Agencies may request investigative subpoenas to gather information needed to develop a basis for establishing and proving an IPV that will be pursued through the ADH process. To request an investigative subpoena:
1.Complete the Request for Investigative Subpoena form (DHS-3436).
2. Include a description of the information being requested and the relevance of the information to establishing the IPV.
3. Send the request to:
Minnesota Department of Human Services.
Appeals Office.
P.O. Box 64941.
St. Paul, MN 55164-0941.
Consider using an investigative subpoena when a third party refuses to provide information.
Refusal to obey an investigative subpoena does not result in a contempt citation. However, these subpoenas are enforceable by appealing to district court for their enforcement by issue of a district court subpoena.
Disqualify people who are found to have committed an Intentional Program Violation (IPV) through any of the following:
l Court conviction (state or federal court).
l Disqualification consent agreement - an agreement between the county attorney and a person accused of committing an IPV in which the person agrees to be disqualified without going to trial.
l Pre-trial diversion - a court-ordered program to refer a person, who has been criminally charged with fraud, to a diversion program. If the person successfully completes the diversion program, one of the following may happen:
n The charges will be dismissed after a specified period of time.
n The charge will be reduced.
n The case will not be charged.
l Administrative Disqualification Hearing (ADH).
l Waiver of an ADH.
Disqualified people cannot receive coverage from the program from which they were disqualified (MinnesotaCare Adults Without Children) for the following time periods:
l 12 months for the first offense.
l 24 months for the second offense.
l Permanently for the third offense.
If only one member of a household is found to have committed an IPV, disqualify only that person. Other household members remain eligible. Continue to count the disqualified member in the household. Deem the disqualified member's income and assets and consider any ESI available through the disqualified member.