1. www.cssny.org COMMUNITY SERVICE SOCIETY COMMUNITY HEALTH ADVOCATES HELPING PATIENTS AND PROVIDERS WITH APPEALS, GRIEVANCES, & FAIR HEARINGS 1

2. Clients should always contact their health plan’s Member Services Department File a complaint, grievance or an appeal (any managed care product- MMC, CHP) If client is not satisfied with the result, he/she can challenge the plan’s decision internally through an appeal or an external review (all managed care products) or with a Medicaid Fair Hearing (MMC only!). 2 When Things Go Wrong

3. A Fair Hearing is a chance for you to tell an Administrative Law Judge (from the Office of Temporary and Disability Assistance) why you think a decision about your case is wrong. Medicaid and consumers have a right to a fair hearing when their benefits have been: Reduced Denied Suspended Terminated or; Client denied exemption (Medicaid only) This applies to their authorization for MA eligibility and access to plan benefits and services 3 Fair Hearing

4. Aid-to-Continue is the continuation of benefits until a fair hearing decision is issued. Appellants must meet two conditions: Medicaid or their health plan wants to reduce, suspend or terminate a treatment, service or covered benefit the individual is currently receiving and; Individual filed a timely request for a Fair Hearing (must be requested within 10 days of notice) 4 Fair Hearing

5. Project FAIR (Fair hearing Assistance Information and Referral) www.projectfair.orgwww.projectfair.org Help Desk - Monday – Friday, from 12:00 p.m. to 3:00 p.m. Advocates at the Help Desk are trained to provide information about Fair Hearings, benefits and community services and, also offer referral services. The Project FAIR Help Desk is located in the main waiting area at: Office of Temporary and Disability Assistance Office of Administrative Hearings 14 Boerum Place, 1st Floor Brooklyn, NY 11201 Tuesdays - Medicaid specialists are there. 5 Helpful Resources Fair Hearing – New York City

6. To request a fair hearing: Fair Hearing Request Form: http://otda.ny.gov/oah/form- request.pdf or E-Request Form: http://otda.ny.gov/oahforms/erequestform.aspx http://otda.ny.gov/oahforms/erequestform.aspx By Fax: Send your fax request 518-473-6735 By Telephone: 518-474-8781 ; Toll Free in NYS: 1-800-342-3334 By Mail: Send your filled out fair hearing request to: Office of Temporary and Disability Assistance (OTDA) Office of Administrative Hearings (OAH) P.O. BOX 1930 Albany, N.Y. 12201-1930 In person (NYC only): OTDA Office of Administrative Hearings at: 14 Boerum Place, 1st Floor, Brooklyn, NY 11201 6 Helpful Resources Fair Hearing – New York City

7. www.cssny.org COMMERCIAL APPEALS 7

8. Appeal Timelines Summary Table 8 Self-Insured Plans (Federal Law) Fully-Insured and Individual Plans (NYS Law) Time to 1 st internal appeal 180 days What gets external review? involves medical judgment rescissions Medical necessity (incl. 4 new types) Exp. /Investigational Out-of-network service What doesn’t get external review? Administrative issues: not a covered benefit, wrong reimbursement amount Time to file for ext. review? Four months Four months for consumers 45 days for providers Time to file for ext. review starts when? Completion of all internal appeals (one or two levels may be required) Except Urgent/Concurrent Care First internal appeal decision (FAD) (even if 2 nd offered) Except Urg./Conc. Care

9. 9 The best places to learn about your right to appeal is your denial notices and Summary Plan Description (sometimes called the certificate of coverage or benefits book). There is some variety among plans, and this presentation only describes the minimum procedures required by law. Golden Rule

10. You can also appeal any Adverse Benefit Determination, which is: “Denial, reduction, termination of, or failure to make payment (in whole or in part) for a benefit” Very broad, covers almost all payment problems Includes denials based on medical judgments Includes denials based on non-medical issues What can be appealed internally?

11. Useful Rights on Appeal first level internal 11 Plans must allow at least 180 days after notice to appeal. Extensions possible with very good excuse. Urgent appeals must be answered within 2 business days max upon receipt of necessary information for fully insured plans For self-insured plans, 72 hours max from filing of appeal On request, enrollees (or authorized reps) can get: Their Summary Plan Description; often only available from HR, not from the plan directly The criteria used, diagnosis codes and treatment codes (and their meaning) related to any adverse benefit determination; Copies of all documents, records, and other info relevant to the claim; Copies of call logs, e.g. from client’s calls to member services Right to appoint a representative to pursue the appeal Tip: Request info from plan quickly, it takes time to get it!

12. Useful Rights on Appeal Second level internal Optional for self insured plans, some plans have a second-level internal appeal, some plans don’t. Same right to access plan documents as first level appeal. Same right to appoint a representative to pursue the appeal. If a plan has two levels of appeal, then it has less time to answer each appeal. Plans normally have 60 days to answer post-service appeals, but only 30 days if they allow two levels of appeal. Note: Reviewer of both level appeals is a plan employee. 12

13. External Review Self-Insured Plans - When is it available? After completion of internal appeals (one level for some plans, two levels of others), FOUR MONTHS to file for external review. For urgent or concurrent care, can file for external review at same time as initial appeal. External review only available for: Decisions “involving medical judgment”; Rescissions (retroactive cancelation of policy) Reviewed by a neutral accredited Independent Review Organization (“IRO”) with medical expertise, contracted by the health plan. 13

14. External Review Fully-Insured Plans – When is it available? 14 External review only available for the following types of denials: Medical necessity, including : Appropriateness e.g. chemotherapy vs. surgery for a cancer Health care setting e.g. breast surgeon vs. general surgeon for a mastectomy Level of care e.g. inpatient vs. outpatient for substance abuse rehabilitation Effectiveness of a covered benefit e.g. is physical therapy still improving your condition? Or not? Experimental / Investigational e.g. is a drug experimental for your illness? Or is there evidence it works? May get patient access to rare disease treatment or clinical trial Out-of-network where alternative treatment available in-network Only available for HMO enrollees No ext. rev. for denial of request to see out-of-network provider Many of these cases newly eligible after Jan 1, 2012

15. External Review Fully-Insured Plans – When is it available? 15 After losing first-level appeal, plan will send a “final adverse determination” (FAD). As of Jan. 1, 2012 enrollee has four months after FAD to file for external review (providers still have only 45 days) Even if plans allow a second-level internal appeal, this does not extend the deadline for filing for external review. External deadline is based on FAD. Tip: Do NOT miss the right to external review because you are waiting for a second-level internal appeal. These appeals get sent to DFS using the standardized External Appeal Application form. Fees: Can’t exceed $25 per review or $75 per year for any enrollee June 2014

16. Note on Formulary Exceptions For Public Health Insurance Plans (Medicaid, Medicare, CHP, QHPs): Guaranteed a formulary exception Doctor’s statement must indicate that the non-formulary drug is necessary for treating an enrollee's condition because all covered drugs on any tier would not be as effective or would have adverse effects For Commercial Health Insurance Plans: No Guaranteed formulary exception Have to check plan documents to see whether plans offer a formulary exception 16

17. Important Caveat – Grandfathered Plans Some aspects of this presentation do NOT apply to “grandfathered” self-insured plans. But the “golden rule” always applies, so check the plan documents. If you still need more help, call us. If you like the insurance you have, you can keep it! President Obama at every speech leading up to ACA’s passage. 17

18. Appeal Options 18 Fair Hearing/Appeal re: eligibility? OTDA Marketplace Fair hearing on benefits? Internal appeals? External appeals? Non-MAGI Medicaid (over 65 or disabled) MAGI Medicaid (under 65 and non- disabled) CHP QHP

19. QUESTIONS 19