IT and Implementation Committee
Managing Appeals and Notifications
June 13, 2012
− Welcome & Overview
− Framing the Essential Question
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15 min
Goals and objectives
Definitions
Questions for IT and Implementation Committee and Board
What appeals are in scope for COHBE?
What notifications are in scope for COHBE?
− Appeals Discussion
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Agenda
20 min
Appeal scenarios
Roles in appeal process
Overview of current HCPF appeal process
Appeals process business requirements
Open Questions on Appeals
− Notifications Discussion
20 min
 Notifications Scenarios
 Notices business requirements
 Open Questions on Notifications
− Next steps
5 min
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Goals and Objectives
Goals and Objectives:
− Support SB 11‐200 intent to increase access, affordability and choice for
individuals and small employers purchasing health insurance in Colorado.
− Facilitate a smooth and efficient appeals process for individuals and employers
– including handoffs between organizations
− Meet the Exchange implementation timeline
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Definitions
− For the purposes of this discussion, the following definition of
appeals is being used:
 an application or proceeding for review by a higher authority, or
 a formal question as to the correctness of a ruling or decision
− Notices will be the method by which COHBE draws attention to,
makes known or announces a decision or change that has impact to
the individual or employer by email or in writing
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Questions for the Committee for today:
− What appeals should the Exchange handle and which should
be referred to other entities?
− What Notices should be generated by the Exchange? (many of
these are identified by current regulations)
− What are the basic business requirements for the Appeals
and Notices processes?
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Scope of Discussion: Appeals
Types of Appeals
Category
Specific Appeal
In Scope for COHBE?
Individual Mandate Exemption
Denial of Exemption
No – Appeal to be passed to
Federal Call Center (at least in
initial years)
Individual Eligibility for public
assistance
Medicaid or CHP eligibility /
information / transfer
No
Individual Eligibility for subsidies
APTC or CSR amount
Yes
Individual APTC / CSR not
applied correctly
APTC or CSR not applied
correctly to premium
Yes
SHOP – Employer appeals
employee eligibility for APTC /
CSR (EEI-19.51)
Employer wants to appeal
determination of employees
eligibility for APTC /CSR
Yes
SHOP Eligibility
Small business eligibility for PTC
Yes
SHOP Eligibility
Small business PTC amount
Yes
SHOP Premium Billing
Amount of bill, payments
received, past due amounts, etc
Yes
The focus
of today’s
discussion
on Appeals
Other types of disputes (e.g., individual billing disputes, coverage issues) are NOT in scope for the
Exchange. These will be handled by carriers, the DOI or other agencies.
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Individual Eligibility Appeals
Exchange
No
Yes
Eligible?
Inform
customer of
eligibility
determination
Apply for
Exemption
Appeal?
Guiding Principle: The appeal process will be handled by the
agency which owns the determination that the customer
desires. For example, if a customer wants Medicaid but was
denied it, HCPF will manage the appeals process; however, if
the customer wants an APTC or feels that a tax credit was
incorrect, COHBE will handle the appeal.
Enter eligibility
Information
Determine
eligibility for
Medicaid / CHP
MAGI
Customer
Federal Agency
Determine
Eligibility for
Individual
Mandate
Exemption
There is also the
opportunity to
appeal if the data
was not
transferred to
PEAK correctly
Appeal?
Yes
Eligible?
Inform
customer of
eligibility and
transfer to
PEAK
Yes
No
Shop for QHPs
Determine
Eligibility for
APTC / CSR
Eligible?
Inform customer
of eligibility
determination for
subsidies
No
Appeal?
Denial of
eligibility for
subsidies
shared with
customer
There is also the
opportunity to appeal if
APTC / CSR is not applied
correctly to the premium
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Inform
Employer of
eligibility
determination
Enter eligibility
Information
Appeal?
Determine
amount of
Premium Tax
Credit
Determine
eligibility for
Premium Tax
Credit
Yes
Apply for
Premium Tax
Credit
Exchange
Employer
SHOP Eligibility Appeals Opportunities
No
Eligible?
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Role in appeals process
Individual/Employee
Initiates eligibility appeals process if not satisfied with Exchange eligibility
determination.
Employer
Initiates eligibility appeals process if not satisfied with Exchange eligibility
determination to purchase on SHOP or for PTC .
Exchange
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•
•
Determines individual eligibility for subsidies.
Notifies individuals of the results of eligibility determinations and provides
information on eligibility appeal rights
Accepts and adjudicates individual appeals regarding eligibility determinations
Process, staffing and timing for resolving appeals is TBD.
DOI
Use existing processes to resolve problems, answer questions, file complaints.
Complaints will include: denial of coverage, claims issues, etc.
Carrier
Use existing internal and external appeals process to handle questions and
disputes related to billing, covered benefits, etc.
Navigator
May initiate eligibility appeals process if not satisfied with Exchange eligibility
determination on behalf of individual
HCPF
Use existing internal and external appeals processes for determining whether
individual is eligible for public assistance programs.
Federal agency
Manage appeals process for individual mandate exemptions.
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Appeals Process Business Requirements
The Appeals process should:
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Include a mechanism for tracking the life cycle of appeals and outcomes
Include the ability to attach documents and other digital material to an appeal
Segregate appeals processes from other activities to ensure proper oversight and
approval levels for appeals activities
Ensure proper notification of all participants in appeals process with enough time to
gather data and review appeals materials
Be able to handle inter-agency disputes
Ensure customer has access to coverage until appeal process is finished (?)
Provide for both an informal appeals resolution process and a formal appeals process.
Include the ability to escalate to a neutral third party.
Follow all applicable laws
Maximize the use of technology such that appeals can be addressed without the Client
having to participate in a face-to-face meeting with a COHBE representative
Use additional data sources as deemed appropriate (by COHBE)
Use self-attestation as appropriate (need to define these conditions)
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For Comparison - Current HCPF Appeals Process
For Medicaid and CHP Eligibility Appeals:
− Client sent notification within ten days of decision regarding eligibility,
enrollment and cost sharing
− An applicant who disagrees with a denial regarding eligibility, enrollment or
cost sharing has 30 days from notification date to appeal decision in writing to
the Office of Administrative Courts
− Department will coordinate appeals process with county or Medical
Assistance site. County or Medical assistance site will review data entry and
application for errors and then notify applicant and Department in writing
once review is complete.
− Client can request dispute resolution conference or formal hearing with
Grievance Committee over the phone or in person
− If eligible person is enrolled in CHP+ or Medicaid, the person can remain
enrolled pending the decision of the appeal
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Other Thoughts for Discussion on Appeals
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Does COHBE want to develop an appeals process that is similar to the HCPF
process in existence today? This can ensure individuals follow a consistent process
and can minimize confusion. Any drawbacks to adopting current HCPF process?
(note – we assume the COHBE contact center will handle the first line of
questions/appeals rather than County or Medical offices for appeals that fall into
the scope of COHBE).
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Is COHBE maximizing efficiencies by building on existing infrastructure to manage
appeals?
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What information needs to be shared between COHBE and its key stakeholders to
ensure individuals and employers are given fair and timely appeals?
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Scope of Discussion: Notices
Types of Notices
Category
Specific Notice
In Scope for COHBE?
Individual Exchange - Change in
Medicaid / CHP eligibility
No longer eligible – go to the Exchange to
check for eligibility for subsidies (APTC /
CSR)
To be discussed – We believe
notice will be generated by
CBMS telling person about
COHBE opportunity
SHOP – Employee no longer
eligible
Employer dropped your coverage – go to the
individual exchange to apply for coverage
Yes
SHOP and Individual - QHP no
longer offered
QHP has been decertified or pulled by
carrier, go to the Exchange and select
another plan
Yes
SHOP and Individual - Open
enrollment notification
Open enrollment period will start soon
Yes
SHOP – Bill past due
Small business payment delinquency notice
Yes
Individual – Bill past due
Exchange received notification from Carrier
that individual is not paying bills
No
SHOP – employer no longer
eligible for PTC
Employer is no longer eligible for PTC due to
change in circumstance
Yes
SHOP – notice to employer that
an employee was determined
eligible for APTC / CSR
One of your employees was determined to
be eligible for APTC / CSP
Yes
SHOP – employer has filed
appeal for employees APTC
Notice to employee that their employer has
filed an appeal disputing the employee’s
eligibility for APTC / CSR
Yes
The focus
for today’s
discussion
on Notices
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Notices are Sent to Individuals:
Notices
− Before open enrollment
− When the Exchange receives information that the individual is no longer
eligible for subsidies on the Exchange due to age, change in MAGI
determination or other life event
− When an employee is no longer covered under an employer’s plan
− When a QHP is no longer available
− If their employer appeals their APTC / CSR eligibility
Notices are sent to Employers:
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When they are delinquent in paying their premium
When a QHP is no longer available
Before open enrollment
When one of their employees is determined to be eligible for APTC / CSR
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Notices Business Requirements
Notices should:
− Be clear, concise and written at the right level and in the right language
for the intended audience
− Be accurate
− Ensure clear notification of actions to be taken, and provide enough time
for the individual or employer to gather data and take appropriate action
− Be ‘legally supportable’
− Be delivered in the most efficient manner, taking into consideration the
customer’s preferences, the need for traceability, and the mission of the
Exchange
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Other Thoughts for Discussion on Notices
− What considerations need to be given during COHBE’s design phase to
ensure the technology platform gives accurate and timely notifications?
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Next Steps
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