Initial Decisions in Medicaid Cases

The ALJ is a representative of the Department throughout the hearing process. As such, the ALJ makes a written recommendation known as the initial decision. Greene v. Dep’t of Cmty. Health, 293 Ga. App. 201, 203 (2008). The initial decision is reviewable by the Department of Community Health. See O.C.G.A. § 49-4-153(b)(1); Ga. R. & Regs. § 616-1-2-.27(4) (defining “initial decision” as one reviewable by the agency). See, generally, O.C.G.A. § 50-13-41.

Federal regulations, at 42 C.F.R. § 431.244(a), provide that hearing recommendations or decisions must be based exclusively on evidence introduced at the hearing. See also O.C.G.A. § 50-13-13(a)(9).

42 C.F.R. § 431.244 provides:

(d) In any evidentiary hearing, the decision must be a written one that—

(1) Summarizes the facts; and
(2) Identifies the regulations supporting the decision.

(e) In a de novo hearing, the decision must—

(1) Specify the reasons for the decision; and
(2) Identify the supporting evidence and regulations.

An administrative law judge shall have all the powers of the ultimate decision maker in the agency with respect to a contested case. O.C.G.A. § 50-13-41(b). Within 30 days after the close of the record, an administrative law judge shall issue a decision to all parties in the case except when it is determined that the complexity of the issues and the length of the record require an extension of this period and an order is issued by an administrative law judge so providing. O.C.G.A. § 50-13-41(c). Every decision of an administrative law judge shall contain findings of fact, conclusions of law, and a disposition of the case. O.C.G.A. § 50-13-41(c). This timetable for rendering a decision appears to comply with 42 C.F.R. § 431.244(f)(1).

An initial decision favorable to the Applicant becomes final unless the agency appeals to the reviewing agency. The reviewing agency for Georgia Medicaid decisions is the Department of Community Health. An initial decision that is not favorable to the Applicant becomes final 30 days after the decision. No action may be taken to reduce or terminate Medicaid until the decision is final. 42 C.F.R. § 431.230(a).

If the decision is adverse to the recipient, then the Department must (a) Inform the applicant or beneficiary of the decision; (b) Inform the applicant or beneficiary that he has the right to appeal the decision to the State agency, in writing, within 15 days of the mailing of the notice of the adverse decision; (c) Inform the applicant or beneficiary of his right to request that his appeal be a de novo hearing; and (d) Discontinue services after the adverse decision. 42 C.F.R. § 431.232; 42 C.F.R. § 431.245. If the decision is adverse to the Department (or if the case is resolved in the beneficiary’s favor without hearing), then the Department must promptly make corrective payments, retroactive to the date an incorrect action was taken. 42 C.F.R. § 431.246. If appropriate, the Department must also provide for admission or readmission to a facility.

Settlement

O.C.G.A. § 50-13-13(a)(4) encourages settlements. It provides “Unless precluded by law, informal disposition may be made of any contested case by stipulation, agreed settlement, consent order, or default.” O.C.G.A. § 50-13-41(b) further provides “Nothing in this article shall affect, alter, or change the ability of the parties to reach informal disposition of a contested case in accordance with paragraph (4) of subsection (a) of Code Section 50-13-13.”