APPEALS PROCESS UNDER HEALTH CARE REFORM - PowerPoint Presentation

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APPEALS PROCESS UNDER HEALTH CARE REFORM

February 25, 2014

County Welfare Directors Association of California

Meg Sheldon

CDSS State Hearings Division

Clare Maudsley, ALJ

Contra Costa County

Yrma VillarrealSlide2

OVERVIEW OF TRAINING

Background to the Affordable Care Act (ACA).

Jurisdiction for MAGI Medi-Cal & Covered California Appeals.Appeals Process.Prehearing Procedures.Hearing Procedures.Post Hearing Procedures.Appeal Rights.2Slide3

NOTE:

The Affordable Care Act refers to the person requesting a hearing as the “appellant”. In Medi-Cal hearings this person is called the “claimant”. Claimant & appellant have the same meaning.

Also, the words “hearing” & “appeal” are interchangeable. 3Slide4

BACKGROUND TO THE AFFORDABLE CARE ACT (ACA)

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BACKGROUND TO THE aca

Affordable Care Act.Qualified Health Plan (QHP).Advanced Payment of Premium Tax Credit (APTC).Cost Sharing Reductions (CSR).Slide6

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Covered cALIFORNIA

One stop shop where applicants are assessed for eligibility for the various programs, purchase private insurance, & enroll with coverage beginning in January 2014.California Healthcare Eligibility, Enrollment & Retention System (CalHEERS) is a new automated system developed to handle applications for health coverage.Slide7

MODIFIED ADJUSTED GROSS INCOME (MAGI)

MEDI-CAL EXPANSION

MAGI Medi-Cal expands Medi-Cal coverage to individuals, including childless adults who have a MAGI of 138% of the Federal Poverty Level ($15,856 for an individual in 2013).Some existing Non-MAGI Medi-Cal programs will still exist.They are: recipients of AFDC medically needy Medi-Cal, with or without a share of cost; aged, blind and disabled; long term care and cash-linked eligibility such as CalWORKs, foster care and adoption assistance. 7Slide8

SINGLE STREAMLINED APPLICATION (SSApp)

Applicants may apply online, by phone, mail, fax, & in person using SSApp to determine eligibility for MAGI Medi-Cal, Covered California, & Non-MAGI Medi-Cal.

Covered California must determine an applicant’s eligibility within 10 days of receipt of application. For Non-MAGI Medi-Cal, a supplemental application is needed which is available from the counties. 8Slide9

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REFERRAL FOR NON-MAGI MEDI-CAL EVALUATION

Covered California will transfer application to counties to determine Non-MAGI Medi-Cal eligibility if:information on SSApp indicates an applicant does not qualify for MAGI Medi-Cal and may be eligible for Non-MAGI Medi-Cal, orapplicant requests the determination.Slide10

JURISDICTION FOR

MAGI MEDI-CAL & COVERED CALIFORNIAAPPEALS

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JURISDICTION

State Hearings Division (SHD) will hear Covered California appeals on:Initial & redetermination of eligibility.Failure to make a timely determination.Fraud cases where Qualified Health Plan (QHP) issuer terminates a QHP.And…Slide12

JURISDICTION

Covered California Continued Enrollment:

Appellant is eligible for continued insurance coverage (QHP) with APTC & CSR, as applicable during appeal. Appellant may request reinstatement of QHP, APTC & CSR up to 90 days after Notice of Action, so long as appellant pays insurance policy premium. Covered California will reinstate QHP, APTC & CSR within 5 days. 12Slide13

APPEALS PROCESS

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MAGI Medi-Cal APPEALS

Initial MAGI Medi-Cal determinations are made by CalHEERS. Counties must verify any additional information needed for a determination and process through CalHEERS for the final Medi-Cal determination which is then forwarded to the county eligibility system [Statewide Automated Welfare System (SAWS) and Medi-Cal Eligibility Data System (MEDS)].Counties responsible for processing MAGI Medi-Cal appeals.Slide15

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APPEALS PROCESS

SHD will hear MAGI Medi-Cal appeals as part of the existing agreement with the Department of Health Care Services (DHCS) for Medi-Cal appeals.SHD will use its existing hearing process for Covered California & MAGI Medi-Cal appeals with a few exceptions.SHD jurisdiction over Non-MAGI Medi-Cal appeals will continue as before.Slide16

PREHEARING PROCEDURES

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Magi medi-cal prehearing process

All MAGI Medi-Cal applications will be inputted into CalHEERS.Eligibility information will be uploaded to SAWS (when programming is in place) where counties will verify eligibility information.When counties have verified eligibility, counties will send out Notice of Action (NOA).Slide18

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“pending eligible” Magi medi-cal

In January 2014, DHCS provided “Presumptive Eligibility” MAGI Medi-Cal benefits to approximately 200,000 applicants, pending verification by counties.Slide19

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PREHEARING PROCEDURES

May submit Appeal Request to SHD Affordable Care Act Bureau (ACAB):in person, by phone,online,by mail, orby FAX.Counties will forward all appeals to ACAB for inputting.Claimant may designate Authorized Representative.Slide20

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Prehearing procedures

Scheduling. Extended notice period: ACAB provides 15 days notice of hearing.Postponements. ACAB will continue to use current “good cause” provisions of Division 22 regarding postponements.Slide21

PREHEARING PROCEDURES

Dismissals.

Appeal will be dismissed if appellant conditionally or unconditionally withdraws, fails to appear, fails to submit a valid appeal request without good cause or dies while the appeal is pending unless appeal affects appellant’s household members or estate. Reopening for “Good Cause”.Dismissal may be vacated if appellant makes a written request within 30 days & shows good cause. 21Slide22

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Prehearing procedures

Unconditional Withdrawal.If after informal resolution process, the claimant chooses to withdraw without conditions, the appeal is dismissed.Slide23

PREHEARING PROCEDURES

Conditional Withdrawal.

If the claimant & Covered California/county reach agreement, they prepare a Conditional Withdrawal (CW) stating the terms & conditions of the agreement. County will rescind the Notice of Action after receipt of the signed CW. If the signed CW is not received 2 days before the hearing, county should, as a best practice, advise the claimant of the non-receipt of the signed agreement.ACAB will provide a Duty Judge who will provide the parties with a telephone hearing to create a record of the pre-hearing disposition, if necessary. 23Slide24

PREHEARING PROCEDURES

Statements of Position (SOP).

Covered California will provide SOPs regarding its jurisdiction: QHP, APTC & CSR. The county of claimant’s residence will prepare the SOP regarding MAGI & Non-MAGI Medi-Cal eligibility determinations.And…24Slide25

PREHEARING PROCEDURES

SOP must be available 2 business days before hearing. Covered California will provide its SOP to the county electronically. County will make its SOP available to the claimant, as before. If claimant requests, county will provide claimant with copy of Covered California’s SOP. Claimant & AR may view the case record & all non-privileged information used by the county prior to or at the hearing.

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PREHEARING PROCEDURES

Dual agency determinations.

Where claimant’s appeal raises disputes that involve both Covered California & the county, the agencies will coordinate.26Slide27

EXPEDITED APPEALS

New standard for Expedited Appeals:

“…where there is an immediate need for services because a standard appeal could jeopardize the claimant’s life or health or ability to attain, maintain, or regain maximum function.”If Expedited Appeal request is granted, ACAB shall schedule hearing within 10 days & notify Covered California & county within 3 business days. 27Slide28

EXPEDITED APPEALS

Expedited appeals decisions will be issued within 10 calendar days of the Notice of Hearing or within 5 business days of the close of record, whichever is later.

Expedited appeals will not go through the informal resolution process.2828Slide29

HEARING PROCEDURES

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HEARING PROCEDURES

May be conducted by Administrative Law Judge by phone or video conference, unless an in-person hearing is requested.

Evidentiary hearing conducted as before ACA.ACAB provides interpreter, if needed, typically by phone.30Slide31

POST HEARING PROCEDURES

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POST HEARING PROCEDURES

Decision sent to claimant by mail & transmitted electronically to Covered California & county.

Compliance by Covered California of favorable decision - at option of appellant: Prospectively – on first day of the month following the date of notice of appeal decision, or Retroactively – to the date the incorrect eligibility determination was made.32Slide33

APPEAL RIGHTS

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APPEAL RIGHTS

For Covered California Issue:

Claimant may appeal to US Department of Health & Human Services.For MAGI & Non-MAGI Medi-Cal Issue: Claimant or county may submit a rehearing request to be reviewed by DHCS.For Any Issue: Claimant or county may request judicial review.34Slide35

QUESTIONS?

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