WellCare, Inc., ALJ Ruling 2026-29 (HHS-CRD June 24, 2026)

DISMISSAL

On February 19, 2026, the Centers for Medicare & Medicaid Services (CMS) terminated WellCare, Inc.’s (Petitioner’s) Medicare provider agreement, effective March 19, 2026, after the California Department of Public Health (CDPH) performed a recertification survey on December 8, 2025, and found that Petitioner was not operational and had ceased business at Petitioner’s approved address of record.  Petitioner filed a request for a hearing before an administrative law judge (ALJ) to dispute the termination, but Petitioner did so eight days beyond the statutory deadline.  I gave Petitioner and CMS an opportunity to provide argument and evidence as to whether the hearing request was late and, if so, whether Petitioner had good cause for filing the request late.  Based on those filings, I conclude that Petitioner’s hearing request was untimely and Petitioner did not have good cause for filing the request late.  Therefore, I dismiss Petitioner’s hearing request. 

I.  Procedural History and Background

Petitioner, located in Concord, California, participated in the Medicare program as a hospice provider.  On December 8, 2025, CDPH attempted to conduct a recertification survey at the Petitioner’s approved address of record.  During the survey, CDPH found

Page 2

that the facility was not operational and had ceased business.  Electronic Filing System (E-File) Doc. No. 1a at 1. 

On December 17, 2025, Petitioner applied for a change of location with CDPH.  E-File Doc. No. 3a. 

On February 19, 2026, CMS informed Petitioner that its participation in the Medicare program as a hospice was terminated effective March 6, 2026, because it did not meet the applicable provisions of the Social Security Act (Act) and Federal Conditions of Participation for Hospices.  E-File Doc. No. 1a at 1.  The notice of termination included the following information on appeal rights: 

If you disagree with the findings of noncompliance which resulted in this imposition, you or your legal representative may request a hearing before an administrative law judge of the Department of Health and Human Services, Departmental Appeals Board (DAB). . . .  A request for a hearing must be filed no later than 60 days from the date of receipt of this notice. 

E-File Doc. No. 1a at 2. 

On May 5, 2026, Petitioner filed with the Civil Remedies Division a hearing request along with a copy of the notice of termination.  E-File Doc. Nos. 1, 1a.  In the hearing request, Petitioner stated that “the circumstances leading to this determination were the result of an ongoing relocation process, rather than a cessation of operations.”  E-File Doc. No. 1.  Petitioner further stated that it had “no intent to discontinue participation in the Medicare program” and it was “prepared to demonstrate full compliance and request[ed] the opportunity for a new survey at the updated location.”  E-File Doc. No. 1. 

On March 7, 2026, I acknowledged receipt of Petitioner’s hearing request and ordered Petitioner to show cause why I should not dismiss the hearing request as untimely.  E-File Doc. No. 2.  In the show cause order, I stated: 

In a February 19, 2026 notice of initial determination, the Centers for Medicare & Medicaid Services (CMS) terminated Petitioner’s participation as a hospice in the Medicaid program.  The notice informed Petitioner that it had the right to request a hearing to dispute the termination and that Petitioner must file such a request with CRD no later than 60 days from the date on which Petitioner received the notice. Petitioner filed the hearing request on May 5, 2026. 

Page 3

As stated in the notice of initial determination, Petitioner had 60 days from the receipt of that notice to file a hearing request.  42 C.F.R. § 498.40(a)(2).  Further, Petitioner is presumed to have received the notice five days after the date on the notice unless there is a reasonable showing to the contrary.  42 C.F.R. § 498.22(b)(3). 

In the present matter, the notice is dated February 19, 2026.  I must presume that Petitioner received the notice on February 24, 2026.  Therefore, Petitioner had to file the hearing request on April 27, 2026. 

I may dismiss an untimely filed hearing request.  42 C.F.R. § 498.70(c).  However, I may extend the time for filing a hearing request when there is a showing of “good cause.” 42 C.F.R. § 498.40(c). 

E-File Doc. No. 2.1 

Petitioner timely responded and provided a copy of the CDPH Change of Location application approval letter.  E-File Doc. Nos. 3, 3a.  On May 11, 2026, I issued an Order, directing CMS to file a reply.  E-File Doc. No. 4.  On June 1, 2026, CMS filed a reply brief to Petitioner’s good cause filing.  E-File Doc. No. 6. 

II.  Discussion

When CMS terminates a provider agreement, the provider has the right to appeal that determination and may request a hearing before an ALJ.  42 C.F.R. §§ 488.1265(f), 498.5(b).  A request for an ALJ hearing to dispute a termination of a provider agreement “must be filed within sixty days after notice of such decision is received by the individual making such request.”  42 U.S.C. §§ 405(b)(1), 1395cc(h)(1).  The presumed receipt date for the initial determination is five days after mailing.  42 C.F.R. §§ 498.22(b)(3), 498.40(a)(2).  An ALJ may extend the due date for a hearing request “[f]or good cause shown.”  42 C.F.R. § 498.40(c)(2). 

The regulations do not define what constitutes “good cause” to extend the filing deadline for a hearing request and the Departmental Appeals Board “has never attempted to provide an authoritative or complete definition of the term ‘good cause’ in section

Page 4

498.40(c)(2).”  Brookside Rehab. & Care Ctr., DAB No. 2094, at 7 n.7 (2007) (citing Glen Rose Med. Ctr. Nursing Home, DAB No. 1852, at 7 n.5 (2002)).  However, a basic definition of “good cause” means “[a] legally sufficient reason.”  Black’s Law Dictionary 11th ed. (2019) (defined under the second definition of the word “cause”).  Therefore, good cause is more than just explaining why a request for hearing is late.  See Brookside, DAB No. 2094, at 7 n.7 (“Here, we need not decide exactly the scope of the ALJ’s discretion under [42 C.F.R. § 498.40(c)] since (under any reasonable definition of that term) the ALJ reasonably determined that [the provider] did not show ‘good cause.’”). 

In the present case, Petitioner filed a hearing request based on a termination notice of its provider agreement for failing to meet the requirements of being operational as defined in the regulations for participation as a hospice provider.  However, as explained in the show cause order, Petitioner filed the hearing request late. 

Petitioner attempts to rebut the presumption that the February 19, 2026 notice of termination was received within five days.  Petitioner explains that “there was a delay in internal receipt and review of the notice by personnel responsible” and “timing of actual awareness occurred significantly later than the presumed receipt date.”  E-File Doc. No. 3 at 2-3. 

Petitioner’s response is inadequate to meet its burden to rebut the presumption of receipt.  Under the regulations, there must be “a showing that [the notice of initial determination] was, in fact, received earlier or later” in order for the five-day presumption of receipt to be rebutted.  42 C.F.R. § 498.22(b)(3).  However, Petitioner does not specify when it believes it received the notice in the mail or even the date when “actual awareness occurred.”  Without specifying an alleged date of receipt, it is impossible to determine whether Petitioner’s hearing request was timely.  Further, Petitioner did not provide any evidence of the date of receipt.  There is no declaration or affidavit from witnesses, or documentation such as a mail log.  Therefore, I must follow the presumption in the regulations, which means that Petitioner’s hearing request is untimely. 

In addition to the argument that Petitioner received the notice of initial determination later than the presumed five days, Petitioner also asserts that it has good cause for an extension of time to file the hearing request.  Petitioner argues that Petitioner had already submitted a Change of Location application with the CDPH by the time CMS issued the February 19, 2026 notice.  E-File Doc. No. 3 at 1.  According to the CDPH letter that Petitioner submitted, CDPH received Petitioner’s Change of Location application on December 17, 2025, and approved it on March 11, 2026.  E-File Doc. No. 3a.  Petitioner argues that:  while awaiting CDPH approval, Petitioner could not lawfully operate at the new location; Petitioner was no longer operating at its prior location; Petitioner did not have active patients and had no billing activity; and Petitioner “was in a regulatory holding period, awaiting state authorization to resume services.”  E-File Doc. No. 3 at 1.  Petitioner alleges the change of location significantly impacted its “ability to timely

Page 5

receive, process, and respond to CMS correspondence.”  E-File Doc. No. 3 at 2.  Further, Petitioner believed that its Medicare certification was temporarily inactive or paused.  E-File Doc. No. 3 at 2. 

CMS disagrees that the situation presented by Petitioner constitutes good cause. 

Petitioner never asserted or proved that it had made CMS aware of a new business address or a new mailing address.  Petitioner closed its business, furthermore, without making adequate arrangements to process its incoming mail -- matters entirely within its control.  Such circumstances do not constitute good cause for extending the deadline for responding to CMS’s notice. 

* * * * *

Furthermore, if Petitioner had been confused about its status in the Medicare program and/or the necessity of responding to CMS’s notice, the notice itself provided instructions for contacting CMS with questions.  Docket Entry 1a, at 3.  It was entirely within Petitioner’s control to choose whether to seek clarification from CMS, so any purported confusion on Petitioner’s part does not constitute good cause for extending the deadline for responding to CMS’s notice. 

E-File Doc. No. 6 at 3, 4. 

I conclude that Petitioner has not made a showing of good cause.  While I understand that the change in location created additional administrative difficulties, I agree with CMS that Petitioner’s failure to make adequate arrangements to timely process its incoming mail during that time was a matter within its control.  Further, Petitioner received both the February 19, 2026 notice of termination and the March 11, 2026 CDPH letter approving the Change of Location application at its original address, which shows that Petitioner was able to process mail sent to that location.  See E-File Doc. Nos. 1a, 3a.  Rather, it seems Petitioner mistakenly relied on its belief that its “Medicare certification would be temporarily inactive or paused, rather than terminated,” and thus, thought “[i]mmediate appeal action was not required.”  E-File No. 3 at 2. 

As a result, Petitioner’s explanation does not provide a legal excuse for failing to timely file a hearing request because Petitioner appears to have simply made a mistake despite the clear statement in the notice that Petitioner’s participation as a hospice provider in the Medicare program would be terminated effective March 6, 2026, and that a hearing request had to be filed no later than 60 days from the receipt of the notice.  See Kids Med

Page 6

(Delta Medical Branch), DAB No. 2471 at 7-8 (2012) (errors causing the late filing of a hearing request are not good cause).  Dismissal of a hearing request is appropriate when the initial determination clearly explained the filing requirements and deadlines to the petitioner.  See Vanguard Vascular & Vein, PLLC, DAB No. 2523, at 3-4 (2013) (upholding dismissal when the reconsidered determination correctly explained in “unambiguous and conspicuous language” that the petitioners had 60 calendar days from their receipt of the reconsidered determination to request a hearing before an ALJ); Waterfront Terrace, Inc., DAB No. 2320, at 6, 8 (2010) (holding that no good cause existed to justify extending the filing deadline where the notice letter reasonably informed the Petitioner of its appeal rights).  Because Petitioner has not made a showing of good cause for filing its hearing request after the expiration of the 60-day deadline, I cannot extend the filing deadline for the hearing request. 

Petitioner claims that “[a]llowing this matter to proceed will not prejudice CMS and will serve the interest of justice,” because “the issues involve substantive regulatory determinations;” “Petitioner has demonstrated good faith efforts to comply with all regulatory requirements;” and “[d]ismissal on procedural grounds would result in substantial hardship.”  E-File Doc. No. 3 at 3.  This amounts to a request for equitable relief.  However, the regulations do not provide ALJs with the authority to grant equitable relief.  See, e.g., US Ultrasound, DAB No. 2302 at 8 (2010) (“Neither the ALJ nor the Board is authorized to provide equitable relief by reimbursing or enrolling a supplier who does not meet statutory or regulatory requirements.”); Foot Specialists of Northridge, DAB No. 2773 at 17-18 (2017) (“Neither the Board nor the ALJs have the authority to “overturn a legally valid agency action on equitable grounds or otherwise grant equitable relief.”); Neb Grp. of Ariz. LLC, DAB No. 2573 at 6 (2014) (“The Board has consistently held that it (and the ALJs) lack the authority to restore a supplier’s billing privileges on equitable grounds.”).  Therefore, I may not consider an untimely hearing request on the merits based on equitable grounds. 

III.  Order

I dismiss Petitioner’s hearing request for untimeliness.