QHP & Medicaid Eligibility Appeals

• The State’s (HSRI’s or EOHHS’s) decision to deny any applicant access to enroll into Medicaid or a QHP;
• HSRI’s decision to deny any applicant access to APTCs or CSRs;
• HSRI’s calculation of APTCs;
• HSRI’s decision to place an applicant into one CSR category as opposed to another;
• HSRI’s decision to terminate any individual from QHP coverage (whether based on nonpayment of premiums or any other justification);
• EOHHS’s decision to terminate any individual from Medicaid coveage;
• HSRI’s decision to change an enrollee’s APTC or CSR eligibility mid-year;
• HSRI’s decision to deny any applicant access to a special enrollment period (SEP);
• HSRI’s decision to deny any application for an exemption from the individual mandate (the requirement that everyone carry or health insurance or else pay a tax penalty);
• HSRI’s decision to charge a particular premium for coverage, if the enrollee thinks the premium should be lower or higher;
• HSRI’s decision to change or adjust premiums in the middle of a coverage year;
• HSRI’s decision to place an enrollee into “pended” status during days 31-90 of the late payment grace period applicable to APTC recipients;
• HSRI’s failure to make an eligibility decision promptly;
• Any retroactive adjustment to an HSRI account that affects the enrollee’s enrollment status, premium, APTC, or CSR in any month.

But some State actions will not be subject to appeal.  Likewise, decisions made by the insurance carrier (rather than by HSRI or EOHHS) must be appealed through different systems with different rules.

Actions Not Subject to Appeal

• EOHHS’s or HSRI’s decision to request further documentation (e.g. of income, of citizenship, etc.)
• Complaints about poor customer service

Insurance Carrier Decisions Subject to Different Types of Appeals

When an enrollee disagrees with a decision or policy of her insurance company (e.g. BlueCross, Neighborhood, or United) rather than a decision or policy of HSRI or EOHHS, the State plays practically no role in the appeal process.  For example, an appeal to the EOHHS appeals office will be fruitless if attempting to challenge the following:

• An insurance company’s decision that a medical service, prescription, or device is not medically necessary;
• An insurance company’s decision to change its prescription formulary;
• An insurance company’s decision to refuse to pay for all or part of a medical service, prescription, or device;
• An insurance company’s decision that a medical service, prescription, or device is experimental and therefore not covered;
• An insurance company’s decision that a particular medical provider is not in the insurer’s provider network;

Most of these decisions can be appealed directly to the insurance company.

Example 1
John applied for coverage through HSRI and was given an APTC of $200 per month.  He thinks he’s eligible for more.
→ John can appeal through the EOHHS appeals office.

Example 2
David was receiving coverage through a QHP purchased on HSRI.  HSRI is now terminating that coverage, saying that David did not pay his premiums.  David disagrees.
→ David can appeal through the EOHHS appeals office.

Example 3
Nelson is covered through a QHP offered by BlueCross BlueShield (BCBS), purchased on HSRI.  Nelson has asthma and has been using Advair for several years.  BCBS recently informed Nelson that it will not cover Advair because the drug is not on its formulary.  Nelson is upset.
→ Nelson may be able to appeal through BCBS, but he cannot appeal to the EOHHS appeals office.  HSRI plays no part in this decision.

Timing / Deadlines

Generally, an applicant or enrollee has 30 days to file an appeal.  The 30-day clock starts to run when an adequate notice about the decision to be appealed is mailed from the State to the applicant or enrollee (or posted to her online account if she has opted to receive notices in this manner).

Some appeals can be accepted even if filed after the 30-day deadline.  One common reason for allowing a late appeal to proceed would be that the appellant has a very good excuse (“good cause”) for filing late. One clear example of good cause would be if the appellant was in the hospital during the appeal period and did not see that notice until he got home.

Once a hearing is requested, the State has 90 days to schedule the hearing, hold the hearing, make a decision, and implement the decision.

Rights to Adequate Notice

When the State (EOHHS or HSRI) makes a determination subject to appeal (see above), it must send a written notice to the applicant or enrollee.  (If the applicant/enrollee opts for online notices, then the State may merely post the notice to the online account, rather than mailing a paper copy.)

All required eligibility notices from the State must be written and must include:

1. An explanation of the action reflected in the notice, including the effective date;
2. Any factual background relevant to the action;
3. Citations to, or identifications of, the relevant regulations supporting the action;
4. Contact information for available customer service; and
5. An explanation of appeal rights, if applicable, including instructions on how to file an appeal and explanation of the circumstances under which eligibility may be maintained or reinstated while the appeal is pending.

Further, all such notices must comply with federal readability and accessibility standards.  These standards include accessibility for individuals living with disabilities in accordance with the Americans with Disabilities Act (ADA).

For individuals with limited English proficiency (LEP), HSRI must provide:

• Oral translation services (at no cost);
• Written translations of notices (at least for some common languages); and
• Taglines in multiple languages informing recipients of the availability of translation services.

At least one EOHHS hearing decision has ruled that English-language notices were inadequate when sent to a Spanish-speaker who had requested Spanish-language notices (allowing that enrollee to proceed with an appeal filed long after the normal 30-day deadline).  A redacted copy of that decision is available here – Appeal Decision REDACTED.

Aid-Continuing / Aid-Pending

Aid-Continuing / Aid-Pending for QHP Enrollees

If an individual is enrolled in a QHP, and a new HSRI decision changes that individual’s enrollment status, APTC, or CSR, then the individual can request to have her benefits continue “unchanged” (i.e. as they were before the new decision) or reinstated while awaiting the hearing and hearing decision.

Unlike with Medicaid appeals (discussed below), federal regulations provide that any HSRI appellant can request aid-continuing, so long as the appeal request is filed within the normal 30-day deadline.

With HSRI appeals, however, aid-continuing can have negative consequences.  If the individual loses the appeal, then the IRS may require that the tax credits provided during the aid-continuing period be paid back.

Aid-Continuing / Aid-Pending for Medicaid Enrollees

For a Medicaid enrollee to receive aid-continuing, he must request the appeal within 10 days of receiving the notice of the action being challenged.  The notice is assumed to have been received 5 days following the date of the notice, unless the person filing the appeal can show that it was not received until later.

Expedited Appeals

An individual may request an expedited appeal where there is immediate need for health services such that a routine appeal could seriously jeopardize the individual’s life, health, or ability to attain, maintain, or regain maximum function.  If EOHHS grants the request for an expedited appeal, then the hearing must be scheduled and the decision issued and implemented as quickly as possible, taking into account the circumstances of the case.

Hearings

Appeals are decided by an impartial hearing officer after an in-person hearing.  Hearings are conducted at DHS offices around the State, with EOHHS usually scheduling hearings at the DHS office closest to the appellant’s home.

Hearings are more formal than a typical DHS meeting, but much more informal than a court proceeding.  The State is normally represented by an HSRI and/or DHS representative.  The hearing officer will ask questions of both sides to try to understand the dispute.  The hearing officer makes an audio recording of the hearing for the record.

The hearing officer rarely makes a decision on the spot.  Most often, the hearing officer takes a few weeks to consider the case and prepare a written opinion, which is then mailed to the parties.  As described above, the State has 90 days after the hearing is requested to schedule the hearing, hold the hearing, issue the decision, and implement the decision.

Appellant’s Rights During Appeal Process

The appellant has a number of rights during the appeal process and at the hearing.  Among these, the appellant has a right:

• to have an attorney or other representative conduct the appeal on her behalf (or simply accompany her to the hearing);
  • To appoint a representative, the appellant must complete two forms – EOHHS Appeal Appointment of Rep Form and EOHHS HSRI Appeal Consent to Release Info Form
• to bring evidence to the hearing;
• to bring witnesses to the hearing;
• to present her case without undue interruption;
• to question or refute any evidence or testimony against her;
• to examine the State’s case file and all evidence to be presented against her, in advance of or at the hearing.
  • It is recommended that an appellant or representative contact the EOHHS hearing office or their state agency contact to request this information well in advance of the hearing.

The appellant can also request that the hearing be rescheduled (also called a “continuance”) if the date/time/place does not work for them.  Up to three requests for continuances will be granted as a matter of course.  If additional continuances are needed, the appellant will need to demonstrate good cause.  (Continuances requested by the appellant delay the State’s 90-day deadline for completing the hearing process.)

If the appellant fails to appear at a hearing, the appeals office should send a written notice and give them an additional 10 day to request that the hearing be rescheduled.  If no such request is made, then the appeal is dismissed and the appellant loses.  An appellant (or representative) should make every effort never to miss a hearing.

Informal Resolution

HSRI may contact appellants to request an “informal resolution” of the dispute.  This is essentially an escalated level of customer service.  If an appellant can resolve an issue to her satisfaction without the need to appear at a hearing, that is always advisable.

But an appellant’s decision to engage or refuse to engage in the informal resolution cannot impact their rights in the appeal process.  No appellant should be pressured to drop her appeal unless she is 100% satisfied with the outcome.

Federal HHS Appeal for QHP-Related Issues

If an appellant is unsatisfied with the result of an appeal about QHPs, APTCs, or CSRs, then she may appeal to the Federal Department of Health and Human Services (HHS).  Appeals to HHS must be filed within 30 days after notice of the EOHHS appeals office decision.

Judicial Review

An appellant who is unsatisfied with the result of an appeal decision may also appeal to the Rhode Island Superior court.  According to current State regulations, there is no need to appeal to the federal HHS system before filing in State court.

Tax Credit Caveat

The final calculation of premium tax credits is made by the IRS.  HSRI merely calculates the “advances” against those tax credits that enrollees can draw down during the year, and those advances are then “reconciled” against the final total during the tax filing process.  The IRS may or may not respect the results of an appeal.  So it is possible to win an appeal and secure a higher APTC, only to learn at the end of the year that the higher amount must be paid back to the IRS.

More Resources:

• 45 C.F.R. Part 155, Subpart F (series of federal regulations on appeals in insurance exchanges)
• 45 C.F.R. § 155.230 (federal regulation on standards for Exchange notices)
• 45 C.F.R. § 155.205(c) (federal regulation on readability and accessibility of notices)
• EOHHS Regulation 0110 (Complaints and Hearings) (State regulation on hearings and appeals for HSRI and for Medicaid)
• RI Dept. of Health Regulation R23-1-1-ACA (HSRI regulation, Section 11 designates EOHHS as HSRI’s appeals entity)
• HSRI Policy and Procedure Manual (Chapter 9)
• Hearing Request Form (for HSRI or Medicaid appeal)
• Appointment of Representative Form 1 of 2 – EOHHS Appeal Appointment of Rep Form
• Appointment of Representative Form 2 of 2 –EOHHS HSRI Appeal Consent to Release Info Form