Menu Close

(10.36) What if my appeal was for a service under the Medi-Cal Home and Community-Based Waiver Program (“DD Waiver”)?

(10.36) What if my appeal was for a service under the Medi-Cal Home and Community-Based Waiver Program (“DD Waiver”)?

You will still have a hearing before an Administrative Law Judge (ALJ) through the Office of Administrative Hearings (OAH).  If your disagreement was about a service under the Medi-Cal Home and Community-Based Waiver program,[1]f the ALJ was able to rule in your favor under the Lanterman Act and there were no questions under the Home and Community Based Services Waiver, the ALJ’s decision is the final decision. it is only a “proposed” decision.  The Lanterman Act says OAH must submit the decision to the Director of Health Care Services to review under federal Medicaid law.  If the Director agrees with the ALJ’s decision, it becomes, “adopted,” which means that decision is final.  They will send you a copy of it.  If the Director makes a new decision, they will send you a copy of the new decision. [2]Section 4712.5(c)

Even though the Lanterman Act says it is the Director of Health Care Services that reviews decisions, the Lanterman Act also says they are allowed to give someone else that authority.[3]Section 4712.7 In the DD Waiver, they give that authority back to the Office of Administrative Hearings. [4]DD Waiver, January 2018, page 235 of 295 So, fair hearings under the DD Waiver are conducted by independent hearing officers with OAH.  Then, the Director of DHCS, the State Medicaid Agency, has given the authority to adopt final decisions to the “Director of OAH.”  If you disagree with the ALJ’s decision, you should ask the Director of OAH to review that decision under federal Medicaid law and give you a final decision.  The OAH Director’s contact information is here: https://www.dgs.ca.gov/OAH/Contact

References
1 f the ALJ was able to rule in your favor under the Lanterman Act and there were no questions under the Home and Community Based Services Waiver, the ALJ’s decision is the final decision.
2 Section 4712.5(c)
3 Section 4712.7
4 DD Waiver, January 2018, page 235 of 295