Office of Conflict Resolution and Appeals Individual Experience Advisory Group June 17, 2014
Appeals as of 06/16/2014 Open: 81 Informal Resolution Process 46 Office of Administrative Courts 4 Pending Withdrawal 31 Closed: 151 Medicaid/CHP+ only Appeals 13 2
Broad Issues of Appeals • Varying or unique income • Ineligible for Medicaid due to immigration status • Population over 65 years old but do not qualify for Medicare and are under 100% FPL • Future date change in minimum essential coverage • Persons with income near or below 400% FPL who do not qualify for APTC due to rating area • Other 3
Filing an Appeal • Appeal rights will be detailed in the Final Eligibility Determination notice (ELG-002-01) and customers will have 30 days from the date of the notice to appeal the Marketplace decision. • Individuals who want to appeal may do so online, by mail, by fax, in person, or over the phone. • When filing an Appeal, it is preferable to use the Appeal Request form. To find this form: o Go to www.connectforhealthco.com Get Started dropdown Individuals and Families o Hit the “Shop Now” button o Scroll to the bottom of the screen and click on “Feedback” o o Under the Appeals section, the Appeal form is available to download 4
Preview of Appeal Request Form 5
Process – Informal Resolution • (1) Intake • (2) Informal Resolution o Informal Resolution is a process where the Office of Conflict Resolution and Appeals will attempt to resolve the issue with the appellant. A team member from OCRA will discuss the eligibility determination process with the appellant, explain to the appellant how the APTC/CSR is determined, and allow the appellant to speak to their appeal. o The appellant does not have to participate in Informal Resolution. It is optional. • If the appellant pursues Informal Resolution, understands the determination, and agrees to withdraw their appeal accordingly, the appeal process will end. • If the appellant pursues Informal Resolution, still disagrees with the determination, they may proceed to a Formal Appeal. • If the appellant does not want to participate in Informal Resolution, they will proceed to a Formal Appeal. • If the appellant does not respond to the Office’s request for Informal Resolution within 15 business days of our request for Informal Resolution, we presume they have opted out of Informal Resolution, and they will proceed to a Formal Appeal. 6
Process • (3) Formal Appeal • A Formal Appeal is a court proceeding. • The Office of Administrative Courts (“OAC”) will appoint an Administrative Law Judge (“ALJ”) to adjudicate and decide these cases. • This is a real court hearing. Parties are required to swear an oath and to provide testimony. • Appellants have the option of obtaining a lawyer or bringing an authorized representative. • The ALJ will render a decision within 90 days of the appellant filing the appeal request form. If the ALJ agrees with the appellant, the Office will change the appellant’s o APTC/CSR determination accordingly. o If the ALJ agrees with the Office, the appellant may appeal again to the U.S. Department of Health and Human Services. However, the determination by C4HCO will remain in place for the time being. o If the case is one that was coordinated between the Office and HCPF, the ALJ will decide eligibility for both programs. 7
Next Steps • Summer Appeals – Special Enrollment Periods • Changes to the application and updates to the Federal Hub will mitigate: o Ineligible for Medicaid due to immigration status o Varying or unique income o Future date change in minimum essential coverage. • Continued collaboration with Medicaid to improve process efficiency and communication channels 8
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