Continued Benefits During Appeal or Fair Hearing. Continuation of benefits without change does not apply when the appeal is based solely on a reduction or elimination of a benefit required by federal or state law affecting some or all beneficiaries, or when the decision does not require the minimum advance notice. If DVHA or the State fair hearing officer reverses a decision to deny, limit, or delay services that were not furnished while the appeal or State fair hearing was pending, DVHA authorizes or provides the disputed services promptly and as expeditiously as the beneficiary’s health condition requires. Beneficiaries may waive their right to continued benefits. If they do so and are successful on an appeal, benefits will be paid retroactively. If DVHA or the State fair hearing officer reverses a decision to deny, limit, or delay services and the beneficiary received the disputed services while the appeal and/or State fair hearing processes were pending, DVHA pays for those services. DVHA may recover from the beneficiary the value of any continued benefits paid during the appeal period when the beneficiary withdraws the appeal before the relevant DVHA or fair hearing decision is made, or following a final disposition of the matter in favor of DVHA. Beneficiary liability will occur only if a DVHA appeal, fair hearing decision, Secretary’s reversal and/or judicial opinion upholds the adverse determination, and DVHA also determines that the beneficiary should be held liable for service costs, and recouping is consistent with state policy. An issue of law or policy means that the person is questioning the legality of a law or rule rather than the facts used or DVHA's judgment in applying the rules to make the decision being appealed.
