CHAPTER9:INDIVIDUALELIGIBILITYANDSHOPAPPEALS
TABLEOFCONTENTS
A. OverviewofHealthSourceRIComplaintsandAppealsProcess...........................................................1
B.ComplaintsProcessRules…………………………………………………………………………………………………………………1
C. AppealsProcessRules..........................................................................................................................2
1) NoticeofAppealRights................................................................................................................2
2) RequestforAppeal.......................................................................................................................2
3) NoticeofReceiptofAppealsRequest..........................................................................................3
4) AppealsAccountManagement....................................................................................................3
5) AssignmentofAuthorizedRepresentative...................................................................................4
6) InformalResolution......................................................................................................................4
7) WithdrawalofHearingRequest...................................................................................................5
8) RequestforaContinuance(Reschedule).....................................................................................5
9) AbandonmentofHearingRequest...............................................................................................5
10) NoticeofHearing.........................................................................................................................6
11) AidPending..................................................................................................................................6
12) SupportiveDocuments................................................................................................................7
13) EvidencePacket...........................................................................................................................7
14) AgencyResponse.........................................................................................................................7
15) AppealHearingModalityandAdjudicators.................................................................................7
16) ExpeditedAppeals.......................................................................................................................8
17) Decisions......................................................................................................................................8
C. Appendix...............................................................................................................................................9
1) SampleAppealForm,Page1........................................................................................................9
2) SampleAppealForm,Page2......................................................................................................10
i
CHAPTER9:INDIVIDUALELIGIBILITYANDSHOPAPPEALS
A.
OverviewofHealthSourceRIComplaintsandAppealsProcess
HealthSourceRIoperatesafullyintegratedandcustomer-centeredcustomerassistancecomplaintsand
appealsprocess.Tothemaximumextentpossible,theprocessenablescustomerstoresolveissuespromptly
andinformally,withthegoalofavoidingtheneedforaformalhearingwhilesimultaneouslysupportinga
customer’srighttopursueahearingwheredesired.1MAGI,MedicaidandHealthSourceRIappealsare
handledinacoordinatedmanneracrossHealthSourceRIandtheExecutiveOfficeofHealthandHuman
Services(EOHHS).2
Applicantsandenrolleesareentitledtoahearingtoappealthefollowingactions:3
•
•
•
•
•
•
•
•
WhethertheyareeligibletobuyaMarketplaceplan,includingaCatastrophichealthinsuranceplan;4
WhethertheycanenrollinaMarketplaceplanoutsidetheregularopenenrollmentperiod;5
Whethertheyareeligibleforlowercostsbasedontheirincome;6
Theamountofsavingstheyareeligiblefor;7
Aredeterminationofeligibility,includingtheamountofAPTCsandlevelofCSRs;8
Whethertheywereproperlyterminatedordis-enrolledfromaQHP;9
Whethertheyareeligibleforanexemptionfromtherequirementtohavehealthinsurance;10and
WhetheremployersoremployeesareeligiblefortheSHOPExchange;11
HealthSourceRIadministersLargeEmployerAppeals,12includingwhethertheemployerprovidesminimum
essentialcoveragethroughanemployersponsoredplanorwhetherthatemployerprovidedcoveragethatis
unaffordable.
B.
ComplaintsProcessRules
Theformalappealsprocessmaynotalwaysbethemostappropriatenorthemostefficientvenueforall
customerissues.Manyquestions,concernsanddisputescanbeinformallyresolvedwithouttheneedfora
hearing.Inmanycases,HealthSourceRIwillbeabletoresolveacustomer’sappealableissuepriortothe
customer’sscheduledhearingdate.Customersarethereforeencouragedtoreportquestionsandconcerns
firstbycalling,mailingorfaxingtheHealthSourceRIContactCenter,orbyloggingintotheiraccountonline
andsubmittingacomplaint.Customersmaysubmitacomplaintbyloggingintotheiraccount,choosingthe
“Tasks”tabontheHomePage,andthenclicking“Fileacomplaint”intheTaskstab.
Complaintsmaybesubmitted:
• byphoneat1-855-840-4774;
______________________________
1
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,V1.0(July26,2013)at9;OHHS0110.
Id.
3
R23-1-1-ACA§1.12;OHHS0110
4
R23-1-1-ACA§1.8(a),§1.8(c);OHHS0110
5
R23-1-1-ACA§1.8(a);OHHS0110
6
R23-1-1-ACA§1.8(b);OHHS0110
7
R23-1-1-ACA§1.8(b);OHHS0110
8
R23-1-1-ACA§1.8(b);OHHS0110
9
R23-1-1-ACA§1.8(d);OHHS0110
10
R23-1-1-ACA§1.13;OHHS0110
11
R23-1-1-ACA§1.30.§1.31;OHHS0110
12
R23-1-1-ACA§1.1;OHHS0110
2
1
•
•
•
bymailatHealthSourceRI,HazardBuildingMailroom,74WestRoad,Suite500,Cranston,RI
02920-8409;
byfaxtotheHealthSourceRICustomerSupportCenterat401-223-6317;or
byaccessingtheiraccountonline,choosingthe“Tasks”tabontheHomePage,andclicking“Filea
Complaint”.
IntheeventHealthSourceRIisabletoaccommodateacustomer’srequesttoretroactivelychangethe
customer’scoveragestartdateoreligibility,itmaytakeupto30daystoprocesstherequest.Accordingly,
onceacustomerhasrequestedachangetohisorhercoverage,thecustomerwillberesponsibleforpaying
fortherequestedcoverageaslongastherequestisprocessedwithin30daysofapproval.
C.
AppealsProcessRules
ThefollowingoutlinestherulesgoverningtheEOHSSappealsprocesses,highlightinganydifferences
betweenindividualeligibilityandSHOPappealsprocesses.
1) NoticeofAppealRights
Customersareprovidedinformationabouttheirappealrightsintheirapplicationpacketandupontheir
eligibilitydetermination.EveryEligibilityDecisionNoticeinformscustomersoftheirrighttoahearing,
proceduresbywhichtorequestahearing,therighttodesignateanauthorizedrepresentativeorhisorher
choosingandthecircumstancesunderwhichaidmaybecontinuedpendinganappeal.13EachEligibility
DecisionNoticealsoincludesanappealrequestform(seeAppendixforasamplecopyoftheAppealsForm).
Medicaidnoticesmustbesentatleast15businessdaysbeforethedateofaction,14andincludeastatement
oftheactiontobetakenbytheagencyandtheeffectivedateofsuchaction,reasonsfortakingtheaction,
sourcesoflaworregulationthatsupporttheaction,andthecustomer’srighttorequestastateMedicaid
agencyhearing.15Noticesmustexplainthattheoutcomeofanappealsdecisionmayresultinachangeof
eligibilityforotherhouseholdmembersandthatsuchachangemaybetreatedasaredetermination.16
Thesamerequirementtoprovideanoticeofappealrightsexistsforemployersandemployeesapplyingfor
eligibilityintheSHOPExchange.17Thenoticeofappealsrightsmustbeincludedinanoticeofdenialissued
toanemployerandemployee.EmployersandemployeesmaybothappealthefailureoftheSHOPExchange
tomakeatimelyeligibilitydecision.18IfanemployerdoesnotincludeanemployeeontheEmployeeCensus,
theemployeewillnotbeeligiblefortheSHOPExchangeandwillnotreceiveadenialofeligibilityfromthe
SHOPExchange.19
2) RequestforAppeal
Customersmustrequestanappealwithin30daysofthedateofthenoticeofeligibilitydetermination.20The
requestmustbefiledorpostmarkedwithinthe30-dayperiod.Thecustomerispresumedtohavereceived
______________________________
13
42CFR431.206andNPRM;42CFR431.210andNPRM;45CFR155.515.
RhodeIslandMedicaidRules&RegulationsCh.0302(D)(1)
15
42CFR431.211andNPRM;42CFR431.210andNPRM.
16
45CFR155.515(b).
17
45CFR155.740(e)(2).
18
45CFR155.740(c)(2)&(d)(2).
19
45CFR155.710(e).
20
OHHSCodeofRules§0110.20.
14
2
thenoticeofaction5businessdaysafterthedateonthenoticeunlessthecustomercanshowthatheorshe
didnotreceiveitwithinthat5-daydayperiod.
RequestsforAppealsmaybesubmitted:
•
•
•
•
•
In-persontotheHealthSourceRIContactCenterortheDHSfieldoffice;
BytelephonethroughtheContactCenter;
ByfaxtotheHealthSourceRICustomerSupportCenter;
ByU.S.Mailtotheaddressindicatedontheappealsrequestform;
Onlinebyaccessingtheuser’saccount,choosingthe“Tasks”tabontheHomePage,andthenclicking
“FileanAppeal”.21
Whensubmittinganappealbymail,customersshouldprovideanexplanation,anddocumentationwhenever
possible,regardingthedecisionbeingchallengedandwhyheorshebelievesthedeterminationis
inaccurate.22Forexample,ifacustomerisappealingaterminationnotice,thecustomershouldsubmitacopy
ofthatnoticealongwiththeappeal.Customerssubmittinganappealfromwithintheironlineaccountare
requiredtoselectthenoticetheyareappealingfromadrop-downmenu,andmayuploadotherrelevant
documentationtotheiraccount.Iffilinganappealonline,customersshouldalsoprovideashortexplanation
regardingthereasonfortheirappealintheboxprovided.
3) NoticeofReceiptofAppealsRequest
EOHHS,uponreceiptofanappealrequest,willsendtimelyacknowledgementtotheappellantofreceiptof
therequest.Theacknowledgementwillincludeinformationregardingpotentialeligibilitypendingappeal,
andmustclarifythatanyAPTCsappliedtotheaccountpendingtheappealaresubjecttoreconciliation.23
BecauseanappealsubmittedbyanemployeecoveredthroughSHOPmayimpacttheemployer,the
employerwillbenotifiedifanemployeesubmitsavalidappeal.24
4) AppealsAccountManagement
Customerscanmanagetheirappealrequestinthesamechannelsthattheysubmittheirappealsrequest:inperson,bymail,bytelephone,byfax,oronline.Fromwithintheironlineaccount,customersmaydesignate
anauthorizedrepresentative,requesttheappealtobeexpedited,choosetowithdrawanappeal,andupload
supportivedocuments.Customersmaybeprovidedanopportunitytoexaminedocumentsandrecordsused
duringthehearing,atareasonabletimebeforethehearing,andduringthehearing.25
IntheSHOPExchange,appellantswillreceive“deskreviews”,althoughhearingrequestswillbeconsidered.26
A“deskreview”meansthehearingofficerreviews,andbaseshis/herdecisionon,writtensubmissionsand
evidencefromtheappellantandanyappropriatestateagencyrepresentative(s).Torequestadeskreview,
theappellantmustnotifytheEOHHSappealsofficeortheHealthSourceRIContactCenterinadvanceand:
______________________________
21
OHHSCodeofRules§0110.20;AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at
9.
22
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at14.
23
45CFR155.520(d)(1).
24
45CFR§155.740(g)(1).
25
OHHS0110.30.25
26
OHHS0110.30.35
3
•
Ifthehearinghasalreadybeenscheduled,thisadvancenoticeshallbegivennolessthanfive
businessdaysbeforethescheduledhearing.Insuchcases,thewrittensubmissionsshallbedueon
thedaythehearingwouldhaveoccurred.
•
Ifthehearinghasnotyetbeenscheduled,theappellantmayrequestthedeskreviewatanytime,
andthewrittensubmissionsshallbeduewithinten(10)daysofsuchrequestoratsuchother
deadlinetobeagreedbetweentheappellantandtheEOHHSCentralAppealsOffice.
Uponrequestingadeskreview,theappellantforfeitshisorheropportunityforanin-personhearing.
5) AssignmentofAuthorizedRepresentative
AppellantshavetherighttodesignateanAuthorizedRepresentativetorepresentthematanystageofan
appeal.27Designationofanauthorizedrepresentativemaybemadeinthefollowingways:
•
•
•
•
BymailinginasigneddocumenttoaDHSofficeortheHealthSourceRICustomerSupportCenter;
ByaddingarepresentativeviatelephonethroughtheContactCenter;
Byaccessingtheironlineaccount;or
Bygoingin-persontotheHealthSourceRIContactCenterorDHSOffice.Ifthedesignationisinperson,a
writtendesignationwillalsoberequired.
ForSHOPappeals,employersandemployeesmayselectanAuthorizedRepresentativespecificallyforan
appealaspartoftheappealrequest.IfanemployeralreadyhasanagentorbrokerasanAuthorized
RepresentativeanddoesnotactivelyselectanAuthorizedRepresentative,theagentorbrokerremainsthe
AuthorizedRepresentativefortheappeal.EmployeesmustactivelyselectanAuthorizedRepresentativefor
anappeal.
AllcorrespondencegeneratedthroughtheEOHHSAppealsOfficeforanappellantwhohasdesignatedan
AuthorizedRepresentativemustbesenttothatrepresentative,inadditiontotheappellant.28
6) InformalResolution
TheInformalResolution(IR)processisafundamentalcomponentoftheappealsprocess.HealthSourceRI
willmakeaconcertedefforttoresolvecustomerdisputespriortotheformalhearingdate.DHSmay
conductinformalresolutionforMAGIMedicaid-relatedappeals.Informalresolutioninvolvesreachingoutto
thecustomeratthetelephonenumberandemailaddresslistedinthecustomer’sonlineaccountandasking
foradditionalinformationthatwillhelpHealthSourceRIresolvetheissue.Everyattemptwillbemadeto
resolvetheappealableissue(s)priortohearing,howeveriftheappellantremainsdissatisfiedwiththe
outcomeoftheIRprocess,hisorherrighttoahearingispreserved.29
Iftheattemptwassuccessful,thecustomerwillbeprovidedanopportunitytowithdrawhisorherformal
hearingrequest.Iftheattemptwasunsuccessful,thecustomer’srighttoaformalhearingstandsandthe
scheduledhearingdateremainsunchanged.30HealthSourceRImaycontinueitseffortstoresolvethe
customer’sissueinformally,upuntilthedateoftheapplicableagency’sdecision,ifnecessary.Iftheappeal
______________________________
27
42CFR435.923(a)and(b);45CFR155.505(e).
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at17.
29
MedicaidRules&Regulations0110.20.05
30
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at24.
28
4
advancestoahearing,theappellantwillnotbeaskedtoprovideduplicativeinformationordocumentation
thatheorshepreviouslyprovidedduringtheapplicationorinformalresolutionprocess.
AninformalresolutionprocessforaSHOPappealmayendineitheraformalappealdecisionortheemployer
oremployeemaywithdrawtheappeal.Similartotheindividualmarketappealsprocess,allwithdrawalsof
appealsmustbeinwriting.31
7) WithdrawalofHearingRequest
Theappealrequestmustbedismissedifanappellantwithdrawstherequestinwritingorbyphone.32When
requestingthewithdrawalthecustomermay:
•
•
•
•
Uploadasignedwithdrawalrequestincustomer’sonlineaccount;
CallHealthSourceRI;
Requestawithdrawalin-personataHealthSourceRIWalk-InCenterbycompletingawithdrawalrequest
form;or
MailorfaxawrittenwithdrawalrequestformtoaDHSFieldOfficeortoHealthSourceRI.33
8) RequestforaContinuance(Reschedule)
AnappellantmustrequesttoreschedulethehearingbycontactingEOHHSAppealsOfficeat(401)462-2132
priortothehearing.NomorethanthreerequestsforcontinuancewillbegrantedunlesstheEOHHSAppeals
Officeexercisesitsdiscretiontoallowformorethanthreecontinuancesafterademonstrationofgood
cause.34
9) AbandonmentofHearingRequest
Ahearingwillbedismissedupondeterminationthatithasbeenabandoned.35Abandonmentoccurwhen,
withoutgoodcause,anindividualorhisorherAuthorizedRepresentativefailstoappearatahearingandhas
notnotifiedtheEOHHSAppealsOfficepriortothehearing.ThecustomermaycalltheEOHHSAppealsOffice
toreschedulethehearingupuntilthetimeofthehearing.
Thecustomerwillbenotifiedinwritingthatthehearingrequestisconsideredabandonedandthatheorshe
maycontacttheEOHHSwithintendaysifheorshewishestoreschedulethehearingandcandemonstrate
goodcauseforfailingtoattendthehearing.36
Goodcauseforfailuretoattendahearingshallinclude,butisnotlimitedto:
•
•
•
Suddenandunexpectedevent(suchaslossorbreakdownoftransportation,illnessorinjury,orother
eventsbeyondtheindividual’scontrol)whichpreventedtheindividual’sattendance;
Injuryorillnessthatreasonablyprohibitedtheindividualfromattending;
Deathinthefamily.37
______________________________
31
45CFR§155.740(i)(1)(i).
45CFR155.530;42CFR431.223;AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at
24;MedicaidRules&Regulations0110.
33
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at34.
34
MedicaidRules&Regulations§0110.40.
35
MedicaidRules&Regulations§0110.40.
36
MedicaidRules&Regulations§0110.40.
32
5
10) NoticeofHearing
Appellantsmustbeprovidedwithwrittennoticeonceahearinghasbeenscheduled.TheEOHHSAppeals
Officewillprovidewrittennoticetotheappellantofthedate,time,andlocationorformatofthehearing
onceitisscheduledandnolaterthan10businessdayspriortothehearingdateandnolaterthan15daysif
itisanappealrelatedtoeligibilityforAPTCsorCSRs.38
ForappealsrelatedtotheSHOPExchange,employersandemployeesbothretaintheoptiontoelecta“desk
review”inlieuofahearing.39Adeskreviewmeansthewrittensubmissionsandevidenceshallbereviewed
andadecisionwillbeissuedbyanEOHHShearingofficer.
SHOPappellantsmayrequestadeskreviewbynotifyingtheEOHHSappealsofficeorHealthSourceRI.Ifthe
hearinghasbeenscheduled,theappellantmayscheduleadeskreviewanytimeatleast10ormoredays
priortothedatethehearingisscheduled.Anappellantmayrequestadeskreviewatanytimeifahearing
hasnotyetbeenscheduled.Evidenceandwrittensubmissionsmustbeprovidedwithin10daysofthe
requestfordeskrevieworatanagreedupondatebetweentheappellantandtheEOHHSCentralAppeals
Office.40
11) AidPending
AcustomerwhofilesanEligibilityAppealmaybeeligibletocontinuetheirpreviouslevelofeligibilitypending
appeal.41Aidpendingisavailabletocustomerswhoappealaneligibilityredeterminationthatoccurredwithin
30daysofthedatetheappealisfiled.ThecustomermustrequesttoreceiveAidPendingbytelephoneto
HealthSourceRIwithin30daysoftheeligibilityredeterminationoccurring.AidPendingislimitedto
customersappealinganeligibilityredetermination.42Newapplicantswhohavebeendeniedeligibilitymay
notreceiveAidPending.43
OnceacustomerisdeterminedeligibletoreceiveAidPending,HealthSourceRIwillcontinuethecustomer’s
eligibilityforenrollmentinaQHP,APTCsandCSRs,asapplicable,inaccordancewiththelevelofeligibilityin
effectimmediatelybeforetheredeterminationbeingappealed.Acustomermustcontinuetopaypremiums
orHSRImayterminatecoverageasprovidedin45CFR155.430(b)(2)(ii).APTCspaidwhiletheappealis
pendingaresubjecttoIRSreconciliationattheendofthetaxyear.Iftheappealresultsinadetermination
thatisunfavorabletothecustomer(e.g.,reducestheamountofAPTCsforwhichheorsheiseligible)the
individualwouldbeliabletorepayAPTCsforwhichtheIRSdeterminesheorsheisnoteligible.
12) SupportiveDocuments
Customershavetheopportunitytosubmitsupportivedocumentsinperson,online,bymail,orbyfaxvia
HealthSourceRI.Documentssubmittedonlinewillbeautomaticallyuploadedtothecustomer’sonline
account.Documentssubmittedin-person,bymail,orbyfaxwillbedigitallyscannedanduploadedintothe
37
MedicaidRules&Regulations§0110.40.
45CFR155.535(b)
MedicaidRules&Regulations§0110.30.35.
40
Id.
38
39
41
45CFR§155.525;R23-1-1-ACA§1.8
45CFR§155.330(e)(1)(ii);45CFR§155.335(h)(1)(ii);78Fed.Reg.169
43
78Fed.Reg.169
42
6
customer’saccountandwillbeincludedintheEvidencePacketforallappealsotherthanSHOP.Documents
submittedforaSHOPappealwillincorporatedintotheevidencepresented.44
13) EvidencePacket
Individualsmustbegiventherighttoexaminetheircasefile/appealrecord,includingalldocumentsand
recordstobeusedduringthehearing,atareasonabletimebeforethedateofthehearingandduringthe
hearing.Customersmustbegiventherighttoquestionorrefuteanyevidencebeingusedintheappeal.45
Requestsforcopiesoftheevidencepacketmaybesubmittedbytelephoneorin-person.
InorderforFederalTaxInformation(FTI)tobeincludedintheevidencepacketandreviewedduringthe
hearing,alladultsinthehouseholdmustsignarelease.TheHearingOfficerandsupportstaffmustalsosign
auseracceptanceforminordertoviewFTI.
IntheSHOPExchange,customersarepermittedtosubmitevidence.46TheExchangewillconsiderrequests
foranevidencepacketforSHOPExchangefromappellantswhoseappealwillbeadjudicatedwithahearing.
14) AgencyResponse
Theresponsibleagencyfortheappealwillprepareanagencyresponsethatwillbepresentedattheappeal
hearingandwillbeincludedintheevidencepacket.Theagencyresponsesummarizestheagency’sfindings,
supportstheoriginalagencyactionandincludestheregulationorpolicyusedforthedecision.Thestate
agency'sresponseshallbereturned,electronicallyormanually,totheEOHHSCentralAppealsOfficewithin
seven(7)days.47
15) AppealHearingModalityandAdjudicators
Appealshearingsmustbeheardorally;conductedatareasonabletime,dateandplace;andadjudicatedby
animpartialhearingofficer.48
AnInterpreterwillbemadeavailableforindividualsneedinginterpretiveservices.
Duringthehearing,thecustomermaypresentadditionaldocumentationandpresenthisorhercasetothe
HearingOfficer,whowillbehearingthecasedenovo(withnopriorknowledgeofthespecificissue).
Thehearingmustberecordedandwitnesseswillbesworninbytheappealsofficer.49Thefollowing
procedureshallbefollowedforeveryhearing:
•
•
Astatementbytheappealsofficerreviewingthehearingpurpose;thereasonforthehearing;the
hearingprocedures;thebasisuponwhichthedecisionwillbemade;andthemannerinwhichthe
individualwillbeinformedofthedecision;
Astatementbytheagencyrepresentativesettingforthepoliciesunderwhichtheactionwastakenor
denied;
______________________________
44
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at34.
42CFR431.242andNPRM;45CFR155.535(d).
46
45CFR§155.740(j).
47
MedicaidRules&Regulations§0110.30.15
48
42CFR431.205(d);42CFR431.240;Proposed45CFR155.505(d);Proposed45FR155.535(c);Preamble4648.
49
OHHSCodeofRules§0110.55.
45
7
•
Astatementbytheclaimant(orhisorherAuthorizedRepresentative)outlininghisorherunderstanding
oftheissue;andafullandopendiscussionofallfactsandpoliciesatissuebyparticipantsunderthe
activeleadershipoftheappealsofficer.50
16) ExpeditedAppeals
Acustomermayrequestanexpeditedprocesswhenthereisanimmediateneedforhealthservicesbecause
astandardappealcouldseriouslyjeopardizethecustomer’slifeorhealthorabilitytoattain,maintainor
regainmaximumfunction.51Iftherequestforanexpeditedappealisdenied,theEOHSSAppealsOfficemust
handletheappealrequestunderthestandardtimeframeandmake“reasonableefforts”toinformthe
appellantthroughelectronicororalnotificationofthedenial.52Expeditedappealrequestswillbereviewed
onacase-by-casebasis.53
ExpeditedappealsarenotavailableforSHOP-relatedappeals.
17) Decisions
Theappealdecisionsmustbewrittenandbasedexclusivelyonrelevantevidenceprovidedduringthecourse
oftheappeal,includingduringthehearing,andapplicablelaw.Decisionsmust:
•
Statethedecision,includingaplainlanguagedescriptionofitseffectonanappellant’seligibility;
•
Summarizethefactsrelevanttotheappeal;
•
Identifythelegalbasisforthedecision,includingtheregulationsthatsupportitandanyandall
conclusionsoflaw;
•
Statetheeffectivedateofthedecision;and
•
Explainthecustomer’srighttopursueanappealwithHHSifheorsheremainsdissatisfiedwiththe
APTC/CSReligibilitydetermination.54
EOHHSwillissuethewrittennoticeoftheappealdecisiontothecustomerwithin30days,55butinnocase
shallexceed90daysoftheappealrequest“asadministrativelyfeasible.”56
EOHSSmustmaketheappealrecordordecisions,asrelevant,accessibletothecustomerataconvenient
placeandtime,andmustalsoprovidepublicaccesstoallappealrecordsordecisionssubjecttoapplicable
federalandstateprivacyandconfidentialitylaws,whichwillrequireredactionsofpersonalinformation
whereappropriate.57EOHHSwillensurethatappealrecordsordecisions,asrelevant,aremadeavailableto
theappellantorthepublicuponrequestandinhardcopyorelectronically.58
______________________________
50
OHHSCodeofRules§0110.55.
45CFR155.540(a);42CFR431.244.
45CFR155.540(b);42CFR431.244(f)(3)
53
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at12.
54
45CFRS.155.545(a),alsoOHHS0110.60
55
OHHSCodeofRules§0110.45.
56
45CFR155.545(b)(1)
57
45CFR155.550
58
Preamble4666
51
52
8
IntheSHOPExchange,theappealrecordmustbeaccessibletoemployersforanemployerappeal.The
appealrecordmustbeaccessibletobothemployersandemployeesforemployeeappeals.59Confidential
informationwillberedactedandSHOPappealswillnotbepubliclyavailable.60
Decisionswillbedisseminatedinwritingtothefollowingpeopleandagencies,dependentupontheprogram
eligibilityofthecustomer:
•
•
•
•
•
•
•
•
•
Appellant
AuthorizedRepresentative,ifassigned
DHSFieldWorker
DHSCaseworkSupervisor
DHSRegionalManager
EOHHSPolicyOffice
AssociateDirector,DivisionofMedicalServices(onlyincaseswhentheMedicaiddecisionwasinfavorof
theappellant)
HealthSourceRILegalCounselandAppealsTeam61
EmployerinthecaseofanemployeeappealintheSHOPExchange.62
Anydecisioninfavoroftheindividualshallapply:63
•
•
Prospectively,onthefirstdayofthemonthfollowingthedateofthenoticeofappealdecision,
orconsistentwith§155.330(f)(2),(3),(4),or(5);or
Retroactively,tothedateoftheincorrecteligibilitydeterminationwasmade,attheoptionof
theappellant.
Additionally,ifadecisionisenteredinfavorofanindividual,HealthSourceRIwillredeterminetheeligibility
ofhouseholdmemberswhohavenotappealedtheirowneligibilitydeterminationsbutwhoseeligibilitymay
beaffectedbytheappealdecision,inaccordancewiththestandardsspecifiedin§155.305.
D.
Appendix
1) SampleAppealForm,Page1
______________________________
59
45CFR§155.740(o)referencing45CFR§155.550
Id.
61
AppealsOperationsManual,RhodeIslandUnifiedHealthInfrastructureProject,Draftv1.0(July26,2013)at10-11.
62
45CFR§155.740(m).
63
45CFR§155.545(c)
60
9
Date:
Account Number:
HEALTHSOURCE RI/EOHHS
HZD MAILROOM
74 WEST ROAD STE 500
CRANSTON RI 02920-8409
Appeal Form
Form Number: OHHS 121
Appeal Request Process
You may request an appeal (a review of our decision) by doing one of the following below. If you submit
this form, the state will complete a review of your case to try to resolve the issue.
·
·
·
Online. Visit www.healthsourceri.com;
By phone. Call (855) 712-9158;
In person. To find an office near you, go to http://www.dhs.ri.gov/tabid/835/Default.aspx or call us at
(855) 712-9158
· By mail or fax. Complete this form and mail it to HZD MAILROOM, 74 WEST ROAD STE 500,
CRANSTON RI 02920-8409 or fax it to 1-401-223-6317
Name (required):
Date of Birth (required):
Account Number :
Address (required):
Phone number:
Email:
Do you need help speaking, reading or writing English?
No
Yes:
If yes, what is your primary language?
Preferred method of contact (circle one): email / paper mail
Please explain the reason for your appeal:
Do you need important health services immediately? If so, would you like an expedited (fast) appeal?
Yes / No. If yes, please explain:
Would you like your coverage and benefits to continue unchanged while you wait for a hearing? Yes /No
!
2) SampleAppealForm,Page2
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Date:
Account Number:
HEALTHSOURCE RI/EOHHS
HZD MAILROOM
74 WEST ROAD STE 500
CRANSTON RI 02920-8409
Appeal Form
Form Number: OHHS 121
Appeal Request Process
You may request an appeal (a review of our decision) by doing one of the following below. If you submit
this form, the state will complete a review of your case to try to resolve the issue.
·
·
·
Online. Visit www.healthsourceri.com;
By phone. Call (855) 712-9158;
In person. To find an office near you, go to http://www.dhs.ri.gov/tabid/835/Default.aspx or call us at
(855) 712-9158
· By mail or fax. Complete this form and mail it to HZD MAILROOM, 74 WEST ROAD STE 500,
CRANSTON RI 02920-8409 or fax it to 1-401-223-6317
Name (required):
Date of Birth (required):
Account Number :
Address (required):
Phone number:
Email:
Do you need help speaking, reading or writing English?
No
Yes:
If yes, what is your primary language?
Preferred method of contact (circle one): email / paper mail
Please explain the reason for your appeal:
Do you need important health services immediately? If so, would you like an expedited (fast) appeal?
Yes / No. If yes, please explain:
Would you like your coverage and benefits to continue unchanged while you wait for a hearing? Yes /No
!
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