1. 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

2. OVERVIEW OF TRAINING 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.

3. 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. 3

4. BACKGROUND TO THE AFFORDABLE CARE ACT (ACA)4

5. BACKGROUND TO THE aca Affordable Care Act.
Qualified Health Plan (QHP).
Advanced Payment of Premium Tax Credit (APTC).
Cost Sharing Reductions (CSR).

6. 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.

7. MODIFIED ADJUSTED GROSS INCOME (MAGI) MEDI-CAL EXPANSION
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).
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. 7

8. SINGLE STREAMLINED APPLICATION (SSApp)
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.
Covered California must determine an applicant’s eligibility within 10 days of receipt of application.
For Non-MAGI Medi-Cal, a supplemental application is needed which is available from the counties. 8

9. 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.

10. JURISDICTION FOR MAGI MEDI-CAL & COVERED CALIFORNIA APPEALS10

11. 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…

12. 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. 12

13. APPEALS PROCESS 13

14. 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.

15. 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.

16. PREHEARING PROCEDURES16

17. 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).

18. “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.

19. 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.

20. 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.

21. 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. 21

22. Prehearing procedures
Unconditional Withdrawal.
If after informal resolution process, the claimant chooses to withdraw without conditions, the appeal is dismissed.

23. 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. 23

24. PREHEARING PROCEDURES
Statements of Position (SOP).
Covered California will provide SOPs regarding its jurisdiction: QHP, APTC & CSR.
The county of claimant’s residence will prepare the SOP regarding MAGI &
Non-MAGI Medi-Cal eligibility determinations.
And… 24

25. PREHEARING PROCEDURES
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. 25

26. PREHEARING PROCEDURES
Dual agency determinations.
Where claimant’s appeal raises disputes that involve both Covered California & the county, the agencies will coordinate. 26

27. 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. 27

28. 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. 28

29. HEARING PROCEDURES 29

30. HEARING PROCEDURES
May be conducted by Administrative Law Judge by phone or video conference, unless an in-person hearing is requested.
Evidentiary hearing conducted as before ACA.
ACAB provides interpreter, if needed, typically by phone. 30

31. POST HEARING PROCEDURES31

32. 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. 32

33. APPEAL RIGHTS 33

34. 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. 34

35. QUESTIONS? 35