There are now reports coming from other states that HHS is telling Obamacare application helpers not to take paper applications but I don't know if HHS is telling the real reason why. The back end software is not functioning and they are not mailing subsidy decision letters by regular mail. Some of the decision letters that are emailed are getting through but not all of them.
What other HHS and journalists are also not telling the public is that people who have not received a decision on their paper application can file an appeal citing the inaction and lack of processing by HHS. They can ask for their insurance to start 1/1/14 even if they don't get a decision letter until several weeks after 12/23/13, They can also contact an ombudsman to complain and they should be calling the Obamacare 800# daily to check on the status of their subsidy application. It is also possible the HHS/CMS will now be vulnerable for class action suits asking for a broad resolution for members of the class that miss the 12/23/13 deadline to pick a health insurance program because of the fact that HHS and WH told the public to file paper apps and there are now extensive delays due to government or its agents incompetence and inaction.
While at SSA I helped process applications for Extra Help for Medicare Prescription Drug Costs which requires people to prove their income and resources. If you would like some background on how we handled this workload and how the software worked let me know. This would be similar to what Serco Corporation is facing in London, KY where all the paper applications are being processed. They have to contact applicants to resolve discrepancies and omissions before making decisions.
Obamacare applicants who do not receive decision letters based on their paper applications because of government delays and inaction can file appeals asking for insurance coverage effective. 1/1/14.
See sections marked with a
1
People who are having a medical emergency can ask for expedited processing of the Appeal.
See Sections marked with a
2
Here is the link that explains how to file an appeal:
https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/
Link on healthcare.gov explaining appeal process and it should but does not mention timeliness as an appealable item or the expedited appeals process for individuals with critical health conditions. The 1 2 appeal form itself does mention the expedited appeals process on page five:
1 2 Found at this link with title "Can I Appeal a Marketplace Decision?":
Found under all topics tab at top of healthcare.gov with title:
"Rights, Protections, and the Law"
45 CFR PART 155—EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT
Link to 45 CFR Part 155:
45 CFR §155.505 General eligibility appeals requirements.
(a) General requirements. Unless otherwise specified, the provisions of this subpart apply to Exchange eligibility appeals processes, regardless of whether the appeals process is provided by a State Exchange appeals entity or by the HHS appeals entity.
(b) Right to appeal. An applicant or enrollee must have the right to appeal—
(1) An eligibility determination made in accordance with subpart D, including—
(i) An initial determination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions, made in accordance with the standards specified in §155.305(a) through (h); and
(ii) A redetermination of eligibility, including the amount of advance payments of the premium tax credit and level of cost-sharing reductions, made in accordance with §§155.330 and 155.335;
(2) An eligibility determination for an exemption made in accordance §155.605;
(3) A failure by the Exchange to provide timely notice of an eligibility determination in accordance with §§155.310(g), 155.330(e)(1)(ii), 155.335(h)(1)(ii), or 155.610(i); and 1
(4) A denial of a request to vacate dismissal made by a State Exchange appeals entity in accordance with §155.530(d)(2), made pursuant to paragraph (c)(2)(i) or this section; and
(c) Options for Exchange appeals. Exchange eligibility appeals may be conducted by—
(1) A State Exchange appeals entity, or an eligible entity described in paragraph (d) of this section that is designated by the Exchange, if the Exchange establishes an appeals process in accordance with the requirements of this subpart; or
(2) The HHS appeals entity—
(i) Upon exhaustion of the State Exchange appeals process;
(ii) If the Exchange has not established an appeals process in accordance with the requirements of this subpart; or
(iii) If the Exchange has delegated appeals of exemption determinations made by HHS pursuant to §155.625(b) to the HHS appeals entity, and the appeal is limited to a determination of eligibility for an exemption.
(d) Eligible entities. An appeals process established under this subpart must comply with §155.110(a).
(e) Representatives. An appellant may represent himself or herself, or be represented by an authorized representative under §155.227, or by legal counsel, a relative, a friend, or another spokesperson, during the appeal.
(f) Accessibility requirements. Appeals processes established under this subpart must comply with the accessibility requirements in §155.205(c).
(g) Judicial review. An appellant may seek judicial review to the extent it is available by law.
...
§155.515 Notice of appeal procedures.
(a) Requirement to provide notice of appeal procedures. The Exchange must provide notice of appeal procedures at the time that the—
(1) Applicant submits an application; and
(2) Notice of eligibility determination is sent under §§155.310(g), 155.330(e)(1)(ii), 155.335(h)(1)(ii), and 155.610(i).
(b) General content on right to appeal and appeal procedures. Notices described in paragraph (a) of this section must contain— 1
(1) An explanation of the applicant or enrollee's appeal rights under this subpart;
(2) A description of the procedures by which the applicant or enrollee may request an appeal;
(3) Information on the applicant or enrollee's right to represent himself or herself, or to be represented by legal counsel or another representative;
(4) An explanation of the circumstances under which the appellant's eligibility may be maintained or reinstated pending an appeal decision, as described in §155.525; and
(5) An explanation that an appeal decision for one household member may result in a change in eligibility for other household members and that such a change will be handled as a redetermination of eligibility for all household members in accordance with the standards specified in §155.305.
§155.520 Appeal requests.
(a) General standards for appeal requests. The Exchange and the appeals entity—
(1) Must accept appeal requests submitted— 1
(i) By telephone;
(ii) By mail;
(iii) In person, if the Exchange or the appeals entity, as applicable, is capable of receiving in-person appeal requests; and
(iv) Via the Internet.
(2) Must assist the applicant or enrollee in making the appeal request, if requested;
(3) Must not limit or interfere with the applicant or enrollee's right to make an appeal request; and
(4) Must consider an appeal request to be valid for the purpose of this subpart, if it is submitted in accordance with the requirements of paragraphs (b) and (c) of this section and §155.505(b).
(b) Appeal request. The Exchange and the appeals entity must allow an applicant or enrollee to request an appeal within—
(1) 90 days of the date of the notice of eligibility determination; or
(2) A timeframe consistent with the state Medicaid agency's requirement for submitting fair hearing requests, provided that timeframe is no less than 30 days, measured from the date of the notice of eligibility determination.
(c) Appeal of a State Exchange appeals entity decision to HHS. If the appellant disagrees with the appeal decision of a State Exchange appeals entity, he or she may make an appeal request to the HHS appeals entity within 30 days of the date of the State Exchange appeals entity's notice of appeal decision or notice of denial of a request to vacate a dismissal.
(d) Acknowledgement of appeal request. (1) Upon receipt of a valid appeal request pursuant to paragraph (b), (c), or (d)(3)(i) of this section, the appeals entity must—
(i) Send timely acknowledgment to the appellant of the receipt of his or her valid appeal request, including—
(A) Information regarding the appellant's eligibility pending appeal pursuant to §155.525; and
(B) An explanation that any advance payments of the premium tax credit paid on behalf of the tax filer pending appeal are subject to reconciliation under 26 CFR 1.36B-4.
(ii) Send timely notice via secure electronic interface of the appeal request and, if applicable, instructions to provide eligibility pending appeal pursuant to §155.525, to the Exchange and to the agencies administering Medicaid or CHIP, where applicable.
(iii) If the appeal request is made pursuant to paragraph (c) of this section, send timely notice via secure electronic interface of the appeal request to the State Exchange appeals entity.
(iv) Promptly confirm receipt of the records transferred pursuant to paragraph (d)(3) or (4) of this section to the Exchange or the State Exchange appeals entity, as applicable.
(2) Upon receipt of an appeal request that is not valid because it fails to meet the requirements of this section or §155.505(b), the appeals entity must—
(i) Promptly and without undue delay, send written notice to the applicant or enrollee informing the appellant:
(A) That the appeal request has not been accepted;
(B) About the nature of the defect in the appeal request; and
(C) That the applicant or enrollee may cure the defect and resubmit the appeal request by the date determined under paragraph (b) or (c) of this section, as applicable, or within a reasonable timeframe established by the appeals entity.
(ii) Treat as valid an amended appeal request that meets the requirements of this section and §155.505(b).
(3) Upon receipt of a valid appeal request pursuant to paragraph (b) of this section, or upon receipt of the notice under paragraph (d)(1)(ii) of this section, the Exchange must transmit via secure electronic interface to the appeals entity—
(i) The appeal request, if the appeal request was initially made to the Exchange; and
(ii) The appellant's eligibility record.
(4) Upon receipt of the notice pursuant to paragraph (d)(1)(iii) of this section, the State Exchange appeals entity must transmit via secure electronic interface the appellant's appeal record, including the appellant's eligibility record as received from the Exchange, to the HHS appeals entity.
§155.525 Eligibility pending appeal.
(a) General standards. After receipt of a valid appeal request or notice under §155.520(d)(1)(ii) that concerns an appeal of a redetermination under §155.330(e) or §155.335(h), the Exchange or the Medicaid or CHIP agency, as applicable, must continue to consider the appellant eligible while the appeal is pending in accordance with standards set forth in paragraph (b) of this section or as determined by the Medicaid or CHIP agency consistent with 42 CFR parts 435 and 457, as applicable.
(b) Implementation. If the tax filer or appellant, as applicable, accepts eligibility pending an appeal, the Exchange must continue the appellant's eligibility for enrollment in a QHP, advance payments of the premium tax credit, and cost-sharing reductions, as applicable, in accordance with the level of eligibility immediately before the redetermination being appealed.
155.540 Expedited appeals. 2
(a) Expedited appeals. The appeals entity must establish and maintain an expedited appeals process for an appellant to request an expedited process where there is an immediate need for health services because a standard appeal could jeopardize the appellant's life, health, or ability to attain, maintain, or regain maximum function.
(b) Denial of a request for expedited appeal. If the appeals entity denies a request for an expedited appeal, it must—
(1) Handle the appeal request under the standard process and issue the appeal decision in accordance with §155.545(b)(1); and
(2) Inform the appellant, promptly and without undue delay, through electronic or oral notification, if possible, of the denial and, if notification is oral, follow up with the appellant by written notice, within the timeframe established by the Secretary. Written notice of the denial must include—
(i) The reason for the denial;
(ii) An explanation that the appeal request will be transferred to the standard process; and
(iii) An explanation of the appellant's rights under the standard process.
§155.545 Appeal decisions.
(a) Appeal decisions. Appeal decisions must—
(1) Be based exclusively on the information and evidence specified in §155.535(e) and the eligibility requirements under subpart D or G of this part, as applicable, and if the Medicaid or CHIP agencies delegate authority to conduct the Medicaid fair hearing or CHIP review to the appeals entity in accordance with 42 CFR 431.10(c)(1)(ii) or 457.1120, the eligibility requirements under 42 CFR parts 435 and 457, as applicable;
(2) State the decision, including a plain language description of the effect of the decision on the appellant's eligibility;
(3) Summarize the facts relevant to the appeal;
(4) Identify the legal basis, including the regulations that support the decision;
(5) State the effective date of the decision; and
(6) If the appeals entity is a State Exchange appeals entity—
(i) Provide an explanation of the appellant's right to pursue the appeal before the HHS appeals entity, including the applicable timeframe, if the appellant remains dissatisfied with the eligibility determination; and
(ii) Indicate that the decision of the State Exchange appeals entity is final, unless the appellant pursues the appeal before the HHS appeals entity.
(b) Notice of appeal decision. The appeals entity—
(1) Must issue written notice of the appeal decision to the appellant within 90 days of the date of an appeal request under §155.520(b) or (c) is received, as administratively feasible.
(2) In the case of an appeal request submitted under §155.540 that the appeals entity determines meets the criteria for an expedited appeal, must issue the notice as expeditiously as reasonably possible, consistent with the timeframe established by the Secretary.
(3) Must provide notice of the appeal decision and instructions to cease pended eligibility to the appellant, if applicable, via secure electronic interface, to the Exchange or the Medicaid or CHIP agency, as applicable.
(c) Implementation of appeal decisions. The Exchange, upon receiving the notice described in paragraph (b), must promptly—
(1) Implement the appeal decision effective—
(i) Prospectively, on the first day of the month following the date of the notice of appeal decision, or consistent with §155.330(f)(2) or (3), if applicable; or
(ii) Retroactively, to the date the incorrect eligibility determination was made, at the option of the appellant. 1
(2) Redetermine the eligibility of household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in §155.305
No comments:
Post a Comment