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 Villarreal
OVERVIEW OF TRAINING
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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.
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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.
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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).
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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.
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MODIFIED ADJUSTED GROSS INCOME (MAGI)
MEDI-CAL EXPANSION
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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).
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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.
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SINGLE STREAMLINED APPLICATION (SSApp)
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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.
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Covered California must determine an applicant’s
eligibility within 10 days of receipt of application.
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For Non-MAGI Medi-Cal, a supplemental
application is needed which is available from the
counties.
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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, or
• applicant requests the determination.
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JURISDICTION FOR
MAGI MEDI-CAL &
COVERED CALIFORNIA
APPEALS
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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…
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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.
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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.
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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.
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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).
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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.
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PREHEARING PROCEDURES
• May submit Appeal Request to SHD Affordable
Care Act Bureau (ACAB):
• in person,
• by phone,
• online,
• by mail, or
• by FAX.
• Counties will forward all appeals to ACAB for
inputting.
• Claimant may designate Authorized Representative.
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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.
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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.
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PREHEARING PROCEDURES
• Unconditional Withdrawal.
• If after informal resolution process, the claimant
chooses to withdraw without conditions, the
appeal is dismissed.
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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.
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PREHEARING PROCEDURES
• Statements of Position (SOP).
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Covered California will provide SOPs
regarding its jurisdiction: QHP, APTC & CSR.
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The county of claimant’s residence will
prepare the SOP regarding MAGI &
Non-MAGI Medi-Cal eligibility
determinations.
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And…
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PREHEARING PROCEDURES
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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.
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Where claimant’s appeal raises disputes that
involve both Covered California & the county,
the agencies will coordinate.
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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.
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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.
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HEARING PROCEDURES
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HEARING PROCEDURES
• May be conducted by Administrative Law Judge
by phone or video conference, unless an inperson hearing is requested.
• Evidentiary hearing conducted as before ACA.
• ACAB provides interpreter, if needed, typically by
phone.
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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.
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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.
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QUESTIONS?
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