Notice and Appeals: Medicaid and the Marketplace

Notice and Appeals Question: What will eligibility notice and appeals processes be for MAGI-Medicaid and Marketplace applicants? Answer: Recent federal regulations have provided some information about guidelines for appeals and notices but we are still at the beginning of understanding exactly how these processes will be implemented in Illinois.

MAGI-Medicaid Appeals What we know: In Illinois, the Marketplace will “assess” eligibility for MAGI-Medicaid but the state will be making the actual eligibility determinations. These determinations will be provided to applicants in writing and, for the time being, will be made under the 45-day decision timeline in the current statute. As a result, the state (BAH) will continue to conduct the fair hearings for those appealing ineligibility determinations—not the Marketplace.

Medicaid Appeals All applications will trigger a written eligibility decision. This notice will include appeal rights and process. Medicaid appeals must be filed within 60 days of the decision. If an applicant is found not eligible for Medicaid on appeal, the state will inform the Marketplace so that the applicant will get connected to health insurance options there. (The exact details of this process are being worked out now.)

MAGI-Medicaid Appeals: Notice Not much substantial change in this process with the exception of: – Electronic Notice Individuals may opt to receive notices electronically—this choice must be confirmed by the agency via regular mail. – Mailing must explain how to change back to mail notices. – After electing this choice, all agency communication can be sent electronically. 42 CFR §

Marketplace Appeals Can appeal: – Initial determination of eligibility, – Amount of premium tax credit, and – Level of cost sharing. Who adjudicates? – In Illinois, probably the HHS appeals entity – Can bring a representative. 45 CFR § et seq.

Marketplace Appeals Notice: – Timing—when applicant submits and application AND on notice of eligibility determination. – Including: explanation of appeal rights; description of how to request an appeal; right to represent self or bring a representative; right to continuing benefits; fact that change may affect whole household.

Marketplace Appeals Appeals must be accepted by telephone, mail, in person (if possible), via internet. Marketplace must assist person in making the appeal if asked; not interfere with right to make an appeal. Time frame: within 90 days of the eligibility determination or timeframe of Medicaid agency for its appeals. Marketplace must send an acknowledgment of the appeal request and if appeal is not valid explain why and how to cure if possible. May be continuing benefits and expedited hearing if applicable. There is an informal resolution process. See 45 CFR et seq.

Appealing Denial of Health Services 9 Refer to Office of Consumer Health Insurance at (877) to file an appeal regarding the plan coverage Contact the state office to appeal Medicaid coverage There is a process to expedite appeals if the person is having a health crisis as a result of the denial. Should be mentioned at the time of the appeal.

Questions/Complaints 10 For the Marketplace: – Office of Consumer Health Insurance (877) – onsumer_Health_Ins.asp onsumer_Health_Ins.asp For Medicaid: – DHS helpline – Local IDHS Family Community Resource Center (FCRC) ule=12 ule=12 – HFS