1. MMAI: Illinois Unified Medicare-Medicaid Appeals Process
August 19, 2014

2. Presenter Information
Department of Healthcare and Family Services, Office of General Counsel
Ryan Tyrrell Lipinski, Bureau Chief and Chief Administrative Law Judge

3. Objective
To provide general overview of Plan responsibilities relating to Grievances and Appeals both at the plan level and at the State Fair Hearing level
To provide reference materials for further information
Answer any questions

4. Resources governing Appeals and Grievances
Federal Regulations governing appeals and grievances: 42 CFR 422, 423, 431 and 438
State Law: Public Aid Code, 305 ILCS 5/11-8 and 305 ILCS 5/11-11(a)(8)
State Law: Managed Care Reform and Patients Right Act, 215 ILCS 134/10, 45, and 50
State regulations:
Fair Hearings, 89 Ill. Adm. Code 104
Managed Care Reform and Patients Right Act, 50 Ill. Adm. Code
MMAI Documents:
Memorandum of Understanding
MMAI 3-way Contract
Chapter 9 Member Handbook Insert
Process Flowchart

5. Commonly Used Terms/Phrases
State Fair Hearing (SFH)=Appeal=Administrative Hearing
Client=Recipient=Beneficiary=Appellant=Grievant =Enrollee=Member=Participant=N.H. Resident
Hearing Officer=Administrative Law Judge
Grievance=Complaint

6. MMAI Grievance and Appeal Process
U.S. Department of Health and Human Services Centers for Medicare & Medicaid Services, the Illinois Department of Healthcare and Family Services and eight Managed Care plans have established an integrated and unified system of appeals for Enrollees.

7. MMAI Grievance and Appeal Process
Huge shift from Fee-For-Service environment
Goal=“Bene-Friendly”
Increased communication
Streamlined approach
Enrollees will have reasons for denials/changes explained to them early on
Formal grievance process will provide avenue for Enrollees to complain about mistreatment
MCOs will provide Enrollee’s with reasonable assistance for completing forms and interpreter services

8. Grievance vs. Appeal
MCOs participating in the MMAI project will have a formally structured Grievance system and a formally structured Appeal system
Important to distinguish difference between a Grievance and an Appeal

9. Grievance vs. Appeal Grievance (Does not come to State Fair Hearings)
Appeal (gives right to a hearing at State level)
Any complaint that is not an appeal of an action
Can be against Provider or MCO
Examples:
Customer service representative unkind
Quality of care
Doctor-patient interaction/rudeness
Failure to respect patient/employee rights
Only Actions can be appealed
Actions are:
Denial of service or payment of service
Denial, termination, reduction in previously authorized service
Failure to provide timely service or a timely appeal
See 42 CFR , 406

10. Part 1: Grievance procedures

11. Grievance Process Internal Grievance Filing:
Enrollee may appoint an Authorized Representative for this process.
Internal Grievance Filing:
May be filed at any time
If Medicare only service, 60 day limit
Can be filed with Provider or MCO
External Grievance Filing:
Enrollees may call 800-Medicare and MCOs will display link on their site )

12. Grievance Process Internal Grievance Process
Informal review: MCO will attempt to resolve Grievances informally
Formal review: For grievances not appropriate for informal review, or denied at the informal level, will be heard by the MCO’s Grievance Committee

13. Grievance Committee Established by the MCO
Must have one Enrollee on the committee
HFS may require that the MCO has one HFS representative on the committee
Cannot have an individual involved in previous level of review on the committee
Will have health care professionals with clinical expertise in treating Enrollee’s condition or disease on the committee, if grievance involves clinical issues
See 42 CFR

14. Grievance Process
MCO will respond, orally or in writing, to each Enrollee Grievance within a reasonable time, but no later than 30 days after receipt of the Grievance
No further appeal or hearing rights with State Fair Hearings for grievances

15. Part 2: Appeals for Enrollees
Describe big picture, two agencies and we get involved formally if not resolved at Plan level.
Standard and Expedited

16. Appeal Process 3 tracks for Appeals
Medicaid-Only
Medicaid-Medicare Overlap (home health, durable medical equipment and skilled therapies)
Medicare-Only
Enrollees may access existing Part D Appeals process for Part D appeals
Counts as internal review, we’ll discuss timeframes in a bit

17. All Appeals-Level 1
MCO must give advance notice of any Adverse Action to Enrollee in form titled “Notice of Adverse Action”
Notice must be given 10 days prior to Action
Notice will provide instructions on how to file an appeal
All appeals must be filed, orally or in writing, initially with the MCO and within 60 calendar days following the date of the Notice of Adverse Action
This is a change from Fee for Service

18. All Appeals-Level 1
Enrollee may appoint an Authorized Representative for the appeal process
Must be in writing
Authorized Representatives include:
Guardians
Caretaker relatives
Providers
Attorneys
Conservators
If client sends an auth rep form to MCO and then subsequently files an appeal with us, we don’t need a separate auth rep form

19. Continuation of Benefits Level 1
For Medicaid services, an Enrollee may continue benefits during a pending appeal if:
The action is appealed within 10 days of MCO Notice of Action
The Enrollee requests the continuation of benefits
For Medicare and Medicare-Medicaid overlap services, the MMAI plan continue benefits pending the Level 1 appeal.
A Enrollee may be held responsible for the cost of benefits if the SFH upholds the MCO’s Appeal Decision, they will be given this warning at the time they opt to continue benefits

20. All Appeals-Level 1 Standard Processing Timeframe: 15 business days
May extend timeframe by 14 calendar days if it’s in the Enrollee’s interest, need permission from State Hearings Office
Expedited Processing Timeframe: 24 hours to inform Enrollee of what information is required; then decision must be made in 24 hours after receipt of required information.
[Checking with BMC regarding holiday/weekend exclusion]

21. SB ILCS 5/5F-32 new
Pursuant to Public Act signed into law on June 16, 2014, all MMAI Managed Care Organizations must allow a nursing home resident’s physician or provider to utilize the MCO expedited appeal process for non-emergency situations when the resident’s physician orders a service, treatment, or test that is not approved by the MCO. 

22. SB ILCS 5/5F-32 new
All MCOs must have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year for nursing home residents.
If the MCO’s response is not provided within 24 hours of the provider’s request and the nursing home is required by regulation to provide a service because a physician ordered it, the MCO must pay for the service if it is a covered service under the MCO's contract in the MMAI Demonstration Project, provided that the request is consistent with the policies and procedures of the MCO.

23. All Appeals-Level 1
During an appeal, the Enrollee and/or representative is afforded:
A reasonable opportunity to present evidence, allegations of fact and law in person as well as in writing
An opportunity, before and during the appeal, to review his or her case file

24. All Appeals-Level 1
MCO will ensure that decision makers for appeal were not involved in previous levels of review and are health professionals with clinical expertise in treating the Enrollee’s condition or disease if:
Appeal is denial of medical necessity
Clinical Issues

25. All Appeals-Level 1
Disposition of Level 1 Appeal will be in the form of Decision Notice
Level 2 will depend on whether the Appeal is:
Medicaid-Only
Medicare-Medicaid Overlap
Medicare-Only

26. Level 2 Medicaid-Only
If Enrollee still wishes to appeal after Level 1, they have options:
File a request for an appeal with the appropriate State Fair Hearing Office within 30 calendar days from date of Decision Notice; and, or,
Decision Notice will inform Enrollee which State Hearing Office
File a request for a review by an Medicaid Independent Review Entity within 30 calendar days from date of Decision Notice
No right to IRE for Waiver program appeals
To file requests with both SFH and IRE

27. Level 2 Medicare-Medicaid Overlap
If the resolution following the Level 1 appeal at the MCO is not in Enrollee’s favor, the Appeal will be automatically be forwarded to the Medicare IRE
Benefits will continue during pendency of IRE review

28. Level 3 Medicare-Medicaid Overlap
If the resolution following the Level 2 appeal at the IRE is not in Enrollee’s favor, Enrollee can choose to file for a State Fair Hearing at the appropriate State Hearing Office or the Enrollee can appeal to a Medicare Administrative Law Judge if the amount if the amount in controversy met ($140 in 2014).

29. Which Agency Handles my Appeal?
DHS
HFS
Medicaid Application eligibility including long term care, CAU (disability,) MAGI/ACA appeals
SNAP (Food Stamp)
Administrative Disqualification Hearing (ADH)
Mental Health (MH)/Division of Alcoholism and Substance Abuse (DASA)
Child care
Waivers
DRS/HSP (Persons with Disabilities, Persons with HIV/AIDs, Traumatic Brain Injury (TBI)
TANF
Medical items/services
Dental
Pharmacy
Transportation
Child Support
Bureau of AllKids determinations
Waivers
Developmental Disability (DD)
Medically Fragile Technologically Dependent Children
Supportive Living Facilities (SLF)
Dept of Aging (DOA)

30. Which Agency Handles “Managed Care Appeals”? Answer: BOTH!
DHS
HFS
HSP/DRS Appeals when MCO make service/items level changes
Mental Health, behavioral health services and prescription drugs/DASA Managed Care Appeals when Plan makes service/item denials
Medical item or service appeals, including pharmacy, transportation, nursing hour reductions, durable medical equipment
Aging Waiver also known as Community Care Program appeals

31. Medicaid-Only Level 2 and Overlap Level 3
Requesting a State Fair Hearing
Medicaid-Only: Information will be included on MCO Appeal Decision Notice
Overlap: Information will be included on IRE decision
Call, , fax or write to us
DHS
HFS
Include a copy of previous level notices
If expedited, Plan will give state notice

32. Continuation of Benefits for State Fair Hearing Level 2 and Overlap Level 3
A Enrollee may continue benefits during a pending appeal if:
The action is appealed within 10 days of MCO Notice of Action or the Appeal Decision Notice
The Enrollee requests the continuation of benefits
A Enrollee may be held responsible for the cost of benefits if the SFH upholds the MCO’s Appeal Decision, they will be given this warning at the time they opt to continue benefits

33. Level 2 Medicaid-Only/ Level 3 Overlap
Enrollee will receive acknowledgment letter and scheduling letter
Default: phone
Evidence
Shall be sent to State Hearing Office and other party at least 3 business days prior to hearing
Parties may present witnesses or documents to support case
Rules of evidence are relaxed
Hearing is digitally recorded but not transcribed
Withdrawals-must be in writing or on the record
DRS Cases—DON score is real issue, then request continuance for DRS Rehab counselor to attend [Check]

34. Level 2 Medicaid-Only/ Level 3 Overlap
Decision Timeframes
Standard: A Final Administrative Decision (FAD) is required to be issued within 90 days, beginning when the initial MCO appeal was filed and not counting Enrollee delay
Expedited: 3 business days after the Enrollee files a request for an expedited SFH
See 42 CFR

35. Level 2 Medicaid-Only/ Level 3 Overlap
State Fair Hearing Final Administrative Decision
Will be sent to all interested parties
Effectuation of Reversed Appeal Decision
If services are not being provided while appeal pending
After reversing the denial of services, the MCO must render promptly and as expeditiously as health care condition requires
If services are being provided while appeal pending
A reversal of a denial must be followed by MCO
Implementation is monitored by State
We have no authority to vacate or reverse our decisions
See 42 CFR

36. Level 3 Medicaid-Only/ Level 4 Overlap
If State Final Administrative Decision is not wholly in favor of the Enrollee, Enrollee can appeal to State Circuit Court for Administrative Review
Under administrative review law, timeframe to file may be as short as 35 days.
We have no authority to vacate or reverse our decisions

37. Medicare A&B-Only
Level 1: Internal MCO appeal, same parameters as others
Level 2: If not fully in favor of Enrollee, auto- forwarded to Independent Review Entity.
Level 3: Medicare Administrative Law Judge (must meet minimum dollar amount and file w/in 60 days)
Level 4: Medicare Appeals Council
Level 5: Federal District Court

38. Medicare Part D (unchanged)
Level 1: Internal MCO appeal. Decision required in 7 days.
Level 2: Appeal to Independent Review Entity (not automatic). Decision required in 7 days.
Level 3: Medicare Administrative Law Judge (must meet minimum dollar amount and file w/in 60 days)
Level 4: Medicare Appeals Council
Level 5: Federal District Court

39. Other Medicare Appeal Rights
Medicare Quality Improvement Organization (QIO) Appeal Rights
The plan must comply with the termination of services notice and appeal requirements for Enrollees receiving services from a hospital, comprehensive outpatient rehabilitation facility, skilled nursing facility, or home health agency, consistent with 42 C.F.R. §§ and

40. Questions?