OAR 309-012-0025: Procedures for Appeals of Reimbursement Orders

(1) Purpose. This rule prescribes procedures for appeals of Reimbursement Orders issued by the Division. (2) Statutory Authority and Procedure. This rule is authorized by ORS 179.640, 413.042 & 179.040 and carries out the provisions of ORS 179.610 to 179.770. (3) Definitions. As used in this rule: (a) “Administrator” means the Administrator of the Addictions and Mental Health Division; (b) “Authorized Representative” means those parties named in ORS 305.240, or those parties who are determined to have the authority to represent the person; (c) “Division” means the Addictions and Mental Health Division of the Oregon Health Authority; (d) “Hearing” means the hearing authorized by ORS 179.640 for the purpose of review of Reimbursement Orders and modified Reimbursement Orders issued pursuant to ORS 179.640; (e) “Hearings Officer” means any person designated by the Administrator to hold hearings on matters coming before the Division. Staff of the Reimbursement Section of the Division may not be designated as hearings officers; (f) “Informal Conference” means a proceeding held before the appeal hearing to allow the person to obtain a review of the action or proposed action without the necessity of a formal hearing; (g) “Person” means: (A) A patient who is receiving or has received treatment or care at a state institution for the mentally ill; (B) A current or former resident at a state institution for the mentally retarded; (C) The estate of the person; (D) Any other individual or entity having a financial interest in contesting a Reimbursement Order. (h) “Reimbursement Order” means the order issued to determine the person’s ability to pay pursuant to ORS 179.640; (i) “Service” means deposit of a Reimbursement Order by U.S. mail, state mail, or deposit with a state institution for hand delivery; (j) “State Institution” means Dammasch State Hospital in Wilsonville, Oregon State Hospital in Salem, Fairview Training Center in Salem, and Eastern Oregon Hospital and Training Center in Pendleton. (4) Authorization for Hearing: A hearing before the Administrator or a Hearings Officer shall be granted to a person who appeals to the Administrator in the following instances: (a) A person may appeal the Division’s determination or redetermination of the person’s ability to pay the state’s charges for institutional care and maintenance. The appeal must be submitted within 60 days of the service of the Reimbursement Order; (b) The Division, on or about the time of the person’s discharge, shall determine whether or not any of the funds previously paid by the person or on his or her behalf to the State of Oregon to cover his or her cost of care should be reimbursed to the person to satisfy his or her financial needs upon release, or whether any of the previous Reimbursement Orders for the current hospitalization should be modified. This redetermination may be appealed within 60 days of service. (5) Request for Hearing: (a) No particular format for a request for a hearing is required, but, to be considered, each request must be in writing and must specify: (A) The name and address of the person requesting the hearing; (B) The action being appealed, including: (i) The year or years involved; (ii) A reference to any Division correspondence on the subject known to the person; (iii) Why the action being appealed is claimed to be incorrect; (iv) The specific relief requested. (b) The request for a hearing must be signed by the person or his or her authorized representative; (c) All requests for hearings shall be filed by mailing or delivering the appeal to the Reimbursement Section, Addictions and Mental Health Division, 500 Summer St. NE, E-86, Salem, OR 97301; (d) If the request for a hearing is considered insufficient in content by the Division, the Division may require the request to be reasonably supplemented with additional information before any further action is taken on the appeal; (e) Prior to the time of an appeal hearing, if there is no objection by the person, the Hearings Officer may refer the matter in controversy for an informal conference for settlement or simplification of issues. (6) Authorization for Informal Conference: (a) A person who has requested an appeal hearing pursuant to section (5) of this rule may request that he or she have an informal conference with a representative from the Reimbursement Section before the formal appeal hearing. Any request for an informal conference may be granted at the discretion of the Division; (b) Such conferences are informal. A person may represent himself or herself or may choose someone to act as his or her representative. The purpose of the conference is to allow a person to obtain a review of the action or proposed action (without the necessity of a formal appeal hearing), if he or she believes that an action made or proposed by the Division is incorrect; (c) Payment of the proposed charge for institutional care and maintenance will not jeopardize a conference request or decision. (7) Request for Informal Conference: (a) A conference request may be filed either with a hearing request required in section (5) of this rule or subsequent to the hearing request but at least 14 days before the date of a scheduled hearing; (b) The conference request shall be in writing and must specify: (A) The name and address of the person requesting the conference; (B) The reason for the request, including: (i) In what respect the action or proposed action of the Division is erroneous; (ii) Reference to any prior Division correspondence on the subject. (c) If a hearing has been requested, the material submitted as part of the request for a hearing may be used at the informal conference; (d) The conference request should be addressed to the Reimbursement Section, Addictions and Mental Health Division, 500 Summer St. NE, E-86, Salem, OR 97301. (8) Conduct of Informal Conference. A conference shall be held at a place designated by the Division. To the extent practical, the conference will be held at a location convenient to the person. The conference shall begin with a statement from the Division. The person requesting the conference shall then state his or her position, the facts as he or she knows them, and his or her questions of persons present to clarify the issues. (9) Disposition of Informal Conference: (a) After the conference, the Reimbursement Section will issue a proposed order disposing of the appeal for approval by the Administrator. The written order, approved by the Administrator, will be sent to the person within 14 days of the conference, unless during the conference the Division action is conceded by the person to be correct; (b) The person’s request for a hearing will be stayed pending the outcome of the conference, at which time the request for a hearing will either be withdrawn by the person should he or she no longer desire to proceed, or the hearing will be rescheduled; (c) When a decision favors the person, the person will receive a refund; (d) The person may request within 30 days that the decision made at an informal conference be reconsidered by the Administrator. The person should set forth the specific ground or grounds for requesting the reconsideration. (10) Subpoenas and Depositions: (a) The Division shall issue subpoenas to any party to a hearing upon request. Witnesses appearing pursuant to subpena, other than parties or employees of the Division, shall receive fees and mileage as prescribed by law for witnesses in a civil action; (b) Depositions may be taken on petition of any party to a hearing. (11) Conduct of Appeal Hearing: (a) To the extent practical, the Division, in designating the location of the hearing, shall designate a place convenient for the person; (b) The hearing shall be conducted by and shall be under the control of the Hearings Officer; (c) The Hearings Officer shall administer an oath or affirmation of the witnesses; (d) A verbatim record shall be made of all testimony and rulings. Parties who wish a transcription of the proceedings should make arrangements with the Division. If the Division determines the record is no longer needed, the Division may destroy the record after 180 days following the issuance of a final order, unless within the 180-day period arrangements are made by the person for further retention by the Division; (e) The hearing shall begin with a statement of the facts and issues involved. The statement shall be given by a person requested to do so by the Hearings Officer; (f) The Hearings Officer may set reasonable time limits for oral presentation and may exclude or limit testimony that is cumulative, repetitious or immaterial. (12) Evidentiary Rules: (a) All evidence of a type commonly relied upon by reasonably prudent persons in conduct of their serious affairs shall be admissible; (b) The Hearings Officer shall receive all physical and documentary evidence presented by parties where practicable. All offered evidence is subject to the Hearings Officer’s power to exclude or limit cumulative, repetitious or immaterial matter; (c) Evidence objected to may be received by the Hearings Officer, and rulings on its admissibility or exclusion may be made at the time a final order is issued; (d) At the time of the hearing, the person will be notified that any exhibit introduced as evidence at the hearing will be destroyed after 180 days following the issuance of a final order, unless within the 180-day period, written request is made by the person presenting the exhibit for the return of the exhibit; (e) The burden of presenting evidence to support a fact or position in a hearing rests on the proponent of the fact or position. (13) Disposition of Appeal: (a) After a hearing has been held, the Hearings Officer shall issue a proposed order, including findings of fact and conclusions of law. If the proposed order is adverse to the person, it shall be served upon the person and an opportunity afforded to the person to file exceptions and present written argument to the Administrator before a final order is issued. A person has a ten-day period in which to file exceptions and/or written argument to a proposed order; (b) Final orders on a hearing shall be in writing and shall include: (A) Rulings on admissibility of offered evidence; (B) Findings of fact — Those matters which are either agreed as fact or which, when disputed, are determined by the Administrator, on substantial evidence, to be a fact over contentions to the contrary; (C) Conclusions of law — Applications of the controlling law to the facts found and the legal results arising there from; (D) The action taken by the Division as a result of the findings of fact and conclusions of law; and (E) Notice of the person’s right to judicial review of the order. (c) Parties to a hearing and their attorneys shall be mailed a copy of the final order and accompanying findings and conclusions. (14) Administrative Review of Final Order: (a) A person may file a petition for administrative review of the final order with the Division within 30 days after the order is served. The petition shall set forth the specific ground or grounds for requesting the review. The petition may be supported by a written argument. Examples of sufficient grounds are: (A) The Division action is not supported by the written findings, or the written findings are inaccurate; or (B) Pertinent information was available at the time of the original hearing which, through no fault of the party, was not considered; or (C) The action of the Division is inconsistent with its rules or policies or is contrary to law; and (D) The matters raised on appeal may have an effect on the original decision. (b) The Division may grant a rehearing petition if sufficient reason therefore is made to appear. The rehearing may be limited by the Division to specific matters. If a rehearing is held, an amended order shall be entered; (c) If the Division denies the appeal, it shall inform the person in writing of the denial; (d) If the administrative review has been requested, the Division order is not final until the administrative review is granted or denied. (15) Time Extensions. Where any provision of this rule specifies a particular time period in which a person must act, for good cause shown, the Hearings Officer may, in his or her discretion, allow a reasonable extension of time if so doing is not inconsistent with ORS 179.640 to 179.650. (16) Appeal. An appeal from the final order of the Division may be taken as provided by law. Caution: Either ORS 179.650 or 183.482 may be applicable. See League of Women Voters v. Lane County Boundary Commission, 32 Or. App. 53, 573P.2d 1255, rev. denied, 283 Or. 503 (1978).