H1886 Summary

• Establishes a permanent appeals process for Medicaid applicants and recipients to challenge adverse determinations (denials, terminations, suspensions, or reductions of covered services) through the Office of Administrative Hearings.

• Requires the Department to provide written notice at least 10 days before an adverse determination becomes effective, including the reason for the action, applicable regulations, appeal rights, and that services continue at prior levels if a hearing is requested before the effective date.

• Applicants and recipients must request a hearing within 30 days of notice and can be represented by an attorney, relative, or other spokesperson; the Department must reinstate services pending the hearing decision.

• Establishes simplified procedures for Medicaid appeal cases, including a goal to schedule hearings within 45 days of appeal request and mandatory mediation attempts through the Mediation Network of North Carolina.

• Shifts burden of proof to the Department when appealing service reductions, terminations, or suspensions; applicants bear the burden for requesting new benefits or services.