The State Medicaid Manual (SMM) is published by the United States Department of Health & Human Services (HHS) Centers for Medicare and Medicaid Services (CMS), formerly known as the Health Care Financing Administration (HCFA).
As explained in its Foreward, at p. i,
"This manual makes available to all State Medicaid agencies, in a form suitable for ready reference, informational and procedural material needed by the States to administer the Medicaid program. It is an official medium by which the Health Care Financing Administration (HCFA) issues mandatory, advisory, and optional Medicaid policies and procedures to the Medicaid State agencies."
SMM § 2904.1 recognizes that "Reopening a final determination permits the correction of errors in that determination. It is particularly suited to changing a determination which was reasonable when rendered but is now unreasonable because new evidence concerning the determination has been submitted which may alter that determination."
In SMM § 2904.1[A] and [B], States are instructed that they may "Reopen An Initial, Revised Determination Or Hearing Decision" upon
"o Written request by the applicant, recipient or his representive (sic), within the time limit, alleging good cause for reopening a previously final determination, or
"o You may, on your own motion, reopen a determination when you have information documenting that the previous determination is incorrect or there is other good cause."
"Good cause" for reopening includes "New and Material Evidence," "Clerical Error," and "Error on the Face of the Evidence." See SMM § 2904.1[C].
SMM § 2904.1[D] informs States that they "may reopen a previously final Medicaid determination within 1 year of that determination when the conditions in paragraph C are met, except when the determination involves fraud. In such cases there is no time limit."
Note: By operation of the opening provision of New York's Medical Assistance (MA) State Plan, "the New York State Department of Health hereby agrees to administer the program in accordance with the provisions of this State plan, the requirements of titles XI and XIX of the Act, and all applicable Federal regulations and other official issuances of the Department."
See New York MA State Plan Submittal Statement, effective October 1, 1996, available at:
http://onlineresources.wnylc.net/FairHearingResources/docs/new_york_medicaid_state_plan_-_submittal_statement__10-01-87_.pdf
Note: The complete State Medicaid Manual is available from CMS at:
http://www.cms.hhs.gov/Manuals/PBM/itemdetail.asp?filterType=none&filterByDID=-99&sortByDID=1&sortOrder=ascending&itemID=CMS021927&intNumPerPage=2000
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