Slide 1: Office of Medicaid Board of Hearings (BOH)
PURPOSE AND ORGANIZATIONAL OVERVIEW
Slide 2: WHAT IS THE BOARD OF HEARINGS?
Governed by:

801 CMR 1.00 – Standard Adjudicatory Rules of Practice and Procedure;

130 CMR 610 – MassHealth Fair Hearing Rules; and

G.L. c. 30A – State Administrative Procedure Act
Slide 3: PURPOSE OF THE BOARD OF HEARINGS 
The Board of Hearings allows “dissatisfied applicants, members, or nursing facility residents to have administrative review of certain actions or inactions on the part of the MassHealth agency and of determinations by a MassHealth managed care contractor.”
Slide 4: TWO TYPES OF HEARINGS AT BOH:
FAIR HEARINGS
(“MEMBER/APPLICANT/NURSING FACILITY RESIDENTS APPEALS”) - approximately 20,000 fair hearing requests filed annually pre-PHE

CLAIMS FOR ADJUDICATORY HEARINGS
(“PROVIDER APPEALS”) –approximately 15,000 active claims for adjudicatory requested annually pre-PHE

Slide 5: HOW A REQUEST FOR A FAIR HEARING BEGINS
DENIAL OF ELIGIBILITY/SERVICES/NURSING FACILITY TRANSFERS OR DISCHARGES

60 days to file an appeal with BOH
Slide 6: MassHealth Fair Hearings
•	Member appeals are governed by federal and state regulations which allow applicants, members/nursing facility residents to have an administrative review of MassHealth actions.
•	Hearing Officers at BOH conduct the fair hearings and adjudicatory hearings (130 CMR 450. 450.241 to 450.248).
•	A member has 60 days from the MH adverse action to appeal
•	(610.015(B)).
•	The date of the request for the fair hearing is the date the request is received by BOH.
•	All appropriate documentation must be submitted with the request for fair hearing.
•	If there is missing documentation, BOH will reach out to secure the additional documentation and allow 10 days for submission of the same.
Slide 7: Process for MassHealth Fair Hearings for Members/Appellants/NF Residents

•	If an appellant fails to timely submit the required documentation, the appeal will be dismissed.
•	If the appellant submits the required documentation in a timely manner, the matter will be scheduled before a Hearing Officer at BOH and a scheduling notice will be sent to all parties at least 4-6 weeks before the hearing
•	The Hearing Officer will conduct the hearing telephonically, by Zoom, in person, or by Teams.
•	All hearings are recorded.
•	The appellant will have reasonable opportunity to examine the appellant’s entire case file as well as all records to be submitted by MassHealth or the MassHealth agency
•	Any party has the right to request a subpoena from the hearing officer requiring the attendance, testimony of witnesses and the production of an evidence relevant to the issues at hearing.
Slide 8: Board of Hearings Workflow
Intake
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•	Appeal received Appeal screened
•	Data entry into case management system
•	Sent to scheduling if appeal is
“perfected”
•	Dismiss or unable appeal if screener identifies issues
Scheduling
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•	Confirm available dates 
•	Create scheduling packet 
•	Quality assurance check 
•	Enter schedules into APS
•	Send out letters/NOAs to all parties
Disposition 
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•	Hearing conducted 
•	Decision issued
•	Decisions due 45 or 90 days from date of filing of FHR
Slide 9: The Intake Unit
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Slide 10: The Gatekeepers
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•	Intake Unit is the first to receive requests for a fair hearing

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•	Ways in which an appeal can be submitted are:
o	Fax/eFax 
o	Mail
o	Phone call (Maximus) AHS 
o	Walk-in
o	Email

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•	Intake Unit screens requests to ensure that it complete and the appeals representative has authority to file an appeal on behalf of the appellant.

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•	Screening process consists of:
o	Is the FHR form signed?
o	Who filed the appeal? Des the appeals representative have authority?
o	Timeliness?
o	Is appeal reason/notice actionable?
o	Aid pending?
Slide 11: Intake Unit Responsibilities 
•	BOH Intake team reviews and screens all fair hearing requests.
•	After screening a request for fair hearing, the Intake team will enter the appeal in the case management system and an appeal number is assigned to the case.
•	If an appeal is missing information, then the intake team member will issue an “unable” letter after the appeal is logged in case management system.
•	Intake will enter aid protection if member qualifies for aid pending. See Eligibility Operations Memo 23-05 dated February 2023
•	If an appeal is perfected, and is data entered, the completed appeal folder is given to the Scheduling Unit.

Slide 12: The Scheduling Unit
This slide shows the image of a weeklong calendar on a wall with post it notes displaying the names of tasks being arranged by a person’s arms. 
Slide 13: Scheduling Unit Responsibilities
•	The goal of the scheduling unit is to have all appeals scheduled, heard, while affording the hearing officer the proper amount of time to write their decision prior to the time compliance deadline (i.e. 45 days, 90 days, etc.)
•	Creating hearing days that are fair and equitable in relation to volume, appeal type, and number of days scheduled (3 hearing days for hearing officers)
•	Reaching out to ACO/MCO/ICO or specific units with MH to mutually agree on a future hearing date
•	Adding on appeals to existing schedules that have openings due to withdraws, reschedules, etc.
•	Sending out Notice of Appeals (“NOAs”) and scheduling letters manually and electronically daily to provide all parties a minimum of 14 calendar days notice of hearing – 6 to 8 weeks advanced notice usually provided.
•	Handling requests to reschedule hearing after Director’s decision.
•	Handling ADA reasonable accommodation requests for the hearing.

Slide 14: Hearing Officer Duties in All Hearings
At the right side of the slide there is the image of a stack of large books with a gavel leaning on them. 

•	To administer the oath of affirmation to witnesses, including interpreters
•	To assist all present to make a full and free statement of the facts
•	To ensure an orderly presentation of all the evidence
•	To ensure all parties have a full opportunity to present their claims orally/ writing and to secure witnesses and evidence to establish their claims
•	To receive, rule on, exclude or limit evidence
•	To ensure a record is made of the proceedings.
•	To render a fair, independent, and impartial decision based on the evidence presented and in accordance with MassHealth regulations and applicable case law.
•	To issue subpoenas.
Slide 15: MassHealth Fair Hearing Decisions
Each of these bullet points are shown in separate boxes in the order written below.

•	The decision of the hearing officer is based on the evidence submitted at hearing and proper applications of the regulations.

•	A hearing decision is rendered within 45/90 days of the date BOH received the appeal.

•	If a party requested time to submit additional information, reschedule or other good cause, the time for the issuance of decision is tolled.

•	The Medicaid Director, may for good cause shown, order the Director of BOH to conduct a rehearing of the appeal.

•	Final decisions of the Hearing Officer are subject to judicial review in the Superior Court pursuant to Rule 30A.
Slide 16: The Dispositions Unit
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Slide 17: Fair Hearing Decisions
This slide shows the image of three rows of different colors of three ring binders on bookshelves.

•	Issues fair hearing decisions via first class mail
•	Maintain logs of all BOH decisions.
•	BOH decisions are available on the MassHealth website.
•	Redacts decisions to ensure privacy.
•	Creates the administrative record if appellant
•	seeks judicial review of a BOH decision.
Slide 18: Judicial Review: G.L. c. 30A, s. 14

If there is a complaint for judicial review, BOH completes and certifies the administrative record and sends a copy to EHS Litigation in the General Counsel’s Office
Slide 19: OneCare Appeals at BOH
•	CONTRACT: Refer to Section 2.12. Enrollee Appeals in Contract Between the US Department of Health and Human Services, Center of Medicare & Medicaid Services In Partnership with the Commonwealth of Massachusetts and Commonwealth Care Alliance, Inc. - Effective January 1, 2022
•	TIME PERIOD TO APPEAL: 60 days from date of notice to file an appeal with BOH – Section 2.12.1.25.
•	NO: BOH does not have jurisdiction over claims involving Medicare Part D (MassHealth covered drugs excluded from Medicare Part D appeals accepted). These appeals will be automatically forwarded to the CMS Independent Review Entity (“IRE”) – 2.12.1.1
•	YES: BOH has jurisdiction over appeals involving “services that are not covered Medicare fee-for-service” 130 CMR 610.018(A) to (C). Overlaps with Home Health, Durable Medical Equipment and skilled therapies accepted but not Medicare Part D. - 2.12.1.2.4.3
•	AID PENDING PROTECTION: If the appellant qualifies, aid pending will be placed by BOH. Federal Medicaid law states that if a member requests a hearing within 10 days from the date they receive a notice of action, MassHealth must reinstate and continue services until a decision is rendered after the hearing upon request - MassHealth Eligibility Operations Memo 23-05 dated February 2023
Slide 20: OneCare Appeals: January 1, 2023 to December 5, 2023
OneCare ICO	
•	Commonwealth Care Alliance
o	Number of Appeals=24
o	Dismissed Outside Hearing=8
o	Withdrawn=0
o	Dismissed at or After Hearing=9
o	Decision – Overturned=1
o	Decision – Upheld=1
o	Pending=5
•	Tufts HP Network Health
•	Number of Appeals=4
•	Dismissed Outside Hearing=4
•	Withdrawn=0
•	Dismissed at or After Hearing=0
•	Decision – Overturned=0
•	Decision – Upheld=0
•	Pending=0

•	United Healthcare ICO
o	Number of Appeals=2
o	Dismissed Outside Hearing=1
o	Withdrawn=0
o	Dismissed at or After Hearing=1
o	Decision – Overturned=0
o	Decision – Upheld=0
o	Pending=0
Totals
o	Number of Appeals=30
o	Dismissed Outside Hearing=13
o	Withdrawn=0
o	Dismissed at or After Hearing=10
o	Decision – Overturned=1
o	Decision – Upheld=1
o	Pending=5
Slide 21: Contact Information
•	Macy Lee, Director – Macy.Lee1@mass.gov
•	BOH Website