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Notes

42 C.F.R. §§ 431.206–431.214

5 sections in range

§431.206. Informing applicants and beneficiaries.

42 C.F.R. § 431.206

(a)
The agency must issue and publicize its hearing procedures.
(b)
The agency must, at the time specified in paragraph (c) of this section, inform every applicant or beneficiary in writing—
(1)
Of his or her right to a fair hearing and right to request an expedited fair hearing;
(2)
Of the method by which he may obtain a hearing;
(3)
That he may represent himself or use legal counsel, a relative, a friend, or other spokesman; and
(4)
Of the time frames in which the agency must take final administrative action, in accordance with § 431.244(f).
(c)
The agency must provide the information required in paragraph (b) of this section—(1) At the time that the individual applies for Medicaid;
(2)
At the time the agency denies an individual's claim for eligibility, benefits or services; or denies a request for exemption from mandatory enrollment in an Alternative Benefit Plan; or takes other action, as defined at § 431.201; or whenever a hearing is otherwise required in accordance with § 431.220(a);
(3)
At the time a skilled nursing facility or a nursing facility notifies a resident in accordance with § 483.15 of this chapter that he or she is to be transferred or discharged; and
(4)
At the time an individual receives an adverse determination by the State with regard to the preadmission screening and annual resident review requirements of section 1919(e)(7) of the Act.
(d)
If, in accordance with § 431.10(c)(1)(ii), the agency has delegated authority to the Exchange or Exchange appeals entity to conduct the fair hearing, the agency must inform the individual in writing that—
(1)
He or she has the right to have his or her hearing before the agency, instead of the Exchange or the Exchange appeals entity; and
(2)
The method by which the individual may make such election;
(e)
The information required under this subpart must be accessible to individuals who are limited English proficient and to individuals with disabilities, consistent with § 435.905(b) of this chapter, and may be provided in electronic format in accordance with § 435.918 of this chapter.
Notes, amendments, and revision history

Amendments

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 58 FR 25784, Apr. 28, 1993; 78 FR 42301, July 15, 2013; 81 FR 68847, Oct. 4, 2016; 81 FR 86448, Nov. 30, 2016]

Source

Source: 44 FR 17932, Mar. 29, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

Amendments

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 58 FR 25784, Apr. 28, 1993; 78 FR 42301, July 15, 2013; 81 FR 68847, Oct. 4, 2016; 81 FR 86448, Nov. 30, 2016]

§431.210. Content of notice.

42 C.F.R. § 431.210

A notice required under § 431.206 (c)(2), (c)(3), or (c)(4) of this subpart must contain—
(a)
A statement of what action the agency, skilled nursing facility, or nursing facility intends to take and the effective date of such action;
(b)
A clear statement of the specific reasons supporting the intended action;
(c)
The specific regulations that support, or the change in Federal or State law that requires, the action;
(d)
An explanation of—
(1)
The individual's right to request a local evidentiary hearing if one is available, or a State agency hearing; or
(2)
In cases of an action based on a change in law, the circumstances under which a hearing will be granted; and
(e)
An explanation of the circumstances under which Medicaid is continued if a hearing is requested.
Notes, amendments, and revision history

Amendments

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 81 FR 86448, Nov. 30, 2016]

Source

Source: 44 FR 17932, Mar. 29, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

Amendments

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 81 FR 86448, Nov. 30, 2016]

§431.211. Advance notice.

42 C.F.R. § 431.211

The State or local agency must send a notice at least 10 days before the date of action, except as permitted under §§ 431.213 and 431.214.
Notes, amendments, and revision history

Amendments

[78 FR 42301, July 15, 2013]

Source

Source: 44 FR 17932, Mar. 29, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

Amendments

[78 FR 42301, July 15, 2013]

§431.213. Exceptions from advance notice.

42 C.F.R. § 431.213

The agency may send a notice not later than the date of action if—
(a)
The agency has factual information confirming the death of a beneficiary;
(b)
The agency receives a clear written statement signed by a beneficiary that—
(1)
He no longer wishes services; or
(2)
Gives information that requires termination or reduction of services and indicates that he understands that this must be the result of supplying that information;
(c)
The beneficiary has been admitted to an institution where he is ineligible under the plan for further services;
(d)
The beneficiary's whereabouts are unknown and the post office returns agency mail directed to him indicating no forwarding address (see § 431.231(d) for procedure if the beneficiary's whereabouts become known). The provisions of this paragraph (d) sunset on October 1, 2034. CMS will follow applicable rulemaking procedures to ensure that policies governing whereabouts unknown are implemented and effective on October 1, 2034, replacing the policies scheduled to sunset on that date;
(e)
The agency establishes the fact that the beneficiary has been accepted for Medicaid services by another local jurisdiction, State, territory, or commonwealth;
(f)
A change in the level of medical care is prescribed by the beneficiary's physician;
(g)
The notice involves an adverse determination made with regard to the preadmission screening requirements of section 1919(e)(7) of the Act; or
(h)
The date of action will occur in less than 10 days, in accordance with § 483.15(b)(4)(ii) and (b)(8), which provides exceptions to the 30 days notice requirements of § 483.15(b)(4)(i) of this chapter.
Notes, amendments, and revision history

Amendments

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 58 FR 25784, Apr. 28, 1993; 78 FR 42301, July 15, 2013; 81 FR 68847, Oct. 4, 2016; 89 FR 22866, Apr. 2, 2024; 91 FR 33469, June 3, 2026]

Source

Source: 44 FR 17932, Mar. 29, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.

Amendments

[44 FR 17932, Mar. 29, 1979, as amended at 57 FR 56505, Nov. 30, 1992; 58 FR 25784, Apr. 28, 1993; 78 FR 42301, July 15, 2013; 81 FR 68847, Oct. 4, 2016; 89 FR 22866, Apr. 2, 2024; 91 FR 33469, June 3, 2026]

§431.214. Notice in cases of probable fraud.

42 C.F.R. § 431.214

The agency may shorten the period of advance notice to 5 days before the date of action if—
(a)
The agency has facts indicating that action should be taken because of probable fraud by the beneficiary; and
(b)
The facts have been verified, if possible, through secondary sources.
Notes, amendments, and revision history

Source

Source: 44 FR 17932, Mar. 29, 1979, unless otherwise noted.

Authority

Authority: 42 U.S.C. 1302.

Source

Source: 43 FR 45188, Sept. 29, 1978, unless otherwise noted.