No Cost Plan to Greatly Improve Obamacare Customer Service

See http://whitecollargreenspace.blogspot.com/
4plan 2have HHS use up to 10,000 empty desks @ 1300 SSA offices to provide Obamacare Walk-in service

Saturday, December 14, 2013

Millions Dis-Insured by Government Delays, Give Them Temporary Medicare Cards; SinglePayer, Try it, We'll Like It‏

January 1, 2014 is D-Day! (Dis-Insured Day)
The Dis-Insured:
There will be millions of Americans who will lose their health insurance because of the good intentions of Obamacare, the idea.  They will be Uninsured because of the poor preparation of Obamacare.  Thousands will suffer. Hundreds will die And then the body count by the Republicans will begin.  And Don't think the Republicans, the Libertarians, and the Tea Party won't go there.  When I graduated from high school, the daily body accounts from Vietnam on the evening news were painfully etched into our minds.  We all knew friends and families who were hurt by the Vietnam War.

The Non-Insured
But that is only half the story.  There will be millions of others who have not had health insurance who have been waiting for the day they are saved from suffering, death, and bankruptcy.  Those who have put off surgery and other medical treatments waiting to be covered.  Their blood is on the hands of the GOP.  Those are the people that the Republicans have voted 4 dozen times to keep them interned in the nightmare land of the uninsured. 

The Only Humane Solution to this problem is for the President to declare a National Emergency and give victims of Healthcare.gov delays who have proof of filing an online or a paper application for Obamacare ,Temporary Medicare coverage for 12 months.+  That is the minimum time period that will be needed to straighten out this mess.  THIS COULD BE THE FIRST STEP TOWARD SINGLE PAYER.  CONSIDER THIS A DEMONSTRATION PROJECT.  IF SOME LIKE THE PLAN, MAYBE WE COULD LET THEM KEEP IT AT THE END OF THE YEAR. This would be a good opportunity for single payer advocate organizations and politicians to coordinate efforts to demand temporary Medicare coverage for those who would have had coverage except for the failure of www.healthcare.gov, etc..



Obamacare is quickly becoming a national disaster.  It took SSA  a whole year when Medicare began in 1965.  And there was no choices to make and no insurance plans involved.  Obamacare reminds me of the Asiana Airline staff who kept ignoring the warnings and crashed the Boeing 777 in San Francisco.  We know what the results were in that case.  We must respond to the Warnings. We must make the administration accountable.  Obamacare regulations state that applicants have a right to the timely processing of their Applications,  they have the right to appeal if they are not timely and they can ask for expedited appeals processing if they are experiencing a medical emergency.  Will HHS be informing people of this?  They did announce the availability of special enrollment periods. Does HHS/CMS have an emergency plan in place to save lives and injury to the millions who have no insurance come January?  Also included below is a plan I submitted that would put Obamacare staff in all 1300 offices of Social Security nationwide.  There is no cost as SSA has 5,000 to 10,000 empty desk/workstations.  Social Security has lost 15% of their staff in the last 5 years.
 
See
http://whitecollargreenspace.blogspot.com/
for a plan to pay for single payer with no increase in taxes and no cuts in other benefits
See
for problems with Obamacare that government won't tell you about and ways to fix them. 
 
Last Week staff from our city Hospital and Obamacare Application Helpers gave a public presentation to explain Obamacare and healthcare.gov.   Many people are having major problems trying to enroll and/or see how much their premiums will be.  That same day I talked to a Walmart employee. She said that she and her husband are uninsured.  She takes no medicine because she can't afford to go to the Dr. and she can't afford the diabetes testing strips.  I told her how to contact the Obamacare workers.  She might get some help from expanded Medicaid, but it will not be in effect until April here in Michigan.  Other Walmart employees told her that some of them were told that Walmart will try to fire some of the full-time employees so they can hire part-time employees.  In addition, local hospital employees heard they might lose their insurance as it does not meet ACA standards.  Those who help patients with low incomes also said that major pharmaceutical companies are scaling back the programs that provide free medicine to those who qualify.  This is another area that needs investigated.  FDA and drug company interest groups may have some data. 

Obamacare is not ready for prime time.  I believe CBO projects that HHS needs to enroll close to 7 million.  Many of them have had coverage and are losing it on 1/1/2014.  How will they get medicine, oxygen, treatment and other supplies for Aids, diabetes, cancer, heart disease, seizures, and on and on.  If we had millions of Americans with the bird flu, FEMA has a plan for that.

http://www.fema.gov/guidance-directives
https://training.fema.gov/EMIWeb/IS/FluPan/References/National_Strategy_for_PI_Nov2005-508.pdf

What if the entire populations of Connecticut and Oregon came down with the bird flu? That's about 7 million people. That would be a national emergency, right.  But wouldn't the fact that millions of Americans are losing there insurance on 1/1/2014 also qualify as a national emergency?  Those hurting are not an homogenous group, geographically or socio-economically.  But they are our neighbors, our relatives, our fellow citizens.  Does Obamacare have an app for that.  Does the White House have a Plan "B."  How about we station Obamacare staff in all 1300 Social Security Offices to work nights and weekends providing 12 month temporary Medicare cards to those who have applied for but not received Obamacare coverage.  This will give the feds, the contractors, the Medicaid agencies, and the insurance companies time to straighten out this mess.  It will take at least 12 months to reach everyone.  Social Security would only have to add two questions to the Medicare application they use right now.  It could be programmed within a week.  What else do we have to do?  We are out of the "war" business.  With no plan "B," Thousands will suffer and Hundreds will die.  That is the fate of those in the nightmare land of the uninsured. 
 
Come January, the WH may not be the Grinch who stole Christmas but it may be the Grinch who stole help and hope from those who are suffering and those who are ill.
The Grinch puzzled and puzzled...till his puzzler was sore.
Then the Grinch thought of something he hadn't before.
Maybe Christmas-he thought--doesn't come from a store.
Maybe Christmas...perhaps...means a little bit more.
Help me! I'm...feeling HONEST?
And what happened then--Well, in Whoville they say...that the Grinch's
small heart grew three sizes that day
but he still had no insurance
due to a government delay!
 
Healthcare.gov online software is still not fixed completely, the paper application software is failing, and the back-end software is a bust.  Now consider the hundreds of insurance companies and the new software they will be using to interface with the government and you can see that it will take at least a year to get Americans enrolled or re-enrolled in life-saving, pain-killing health insurance. 
God Help Us.

http://en.wiktionary.org/wiki/disinsure#English

Verb

disinsure (third-person singular simple present disinsures, present participle disinsuring, simple past and past participle disinsured)
  1. (obsolete) To render insecure; to put in danger.

Tuesday, December 10, 2013

Will Obamacre Be Obama's Vietnam? Will Medicare Be the Savior of Obamacare?


January 1, 2014 is D-Day!
 
There will be millions of Americans who will lose their health insurance because of the good intentions of Obamacare, the idea.  They will be Uninsured because of the poor preparation of Obamacare.  Thousands will suffer.  Hundreds will die.  And then the body count by the Republicans will begin.  And Don't think the Republicans, the libertarians, and the Tea Party won't go there.  I graduated from high school and the daily body accounts from Vietnam on the evening news   are painfully etched into our minds.  We all knew friends and families who were hurt by the Vietnam War.

But that is only half the story.  There will be millions of others who have not had health insurance who have been waiting for the day they are saved from suffering, death, and bankruptcy.  Those who have put off surgery and other medical treatments waiting to be covered.  Their blood is on the hands of the GOP.  Those are the people that the Republicans have voted 4 dozen times to keep them interned in  the nightmare land of the uninsured. 


The Only Humane solution to this problem is for the President to declare a National Emergency and give anyone with proof of filing an online or a paper application for Obamacare  Temporary Medicare coverage for 6 to 12months.  That is the minimum time period needed to straighten out this mess. There are empty desks available in all 1300 Social Security Offices nationwide that could be staffed quickly to process the new Medicare cards. See http://whitecollargreenspace.blogspot.com/ for details.   
 
+
Healthcare.gov online software is still not fixed completely, the paper application software is failing, and the back-end software is a bust.  Now consider the hundreds of insurance companies and the new software they will be using to interface with the government and you can see that it will be at least a year to get Americans enrolled or re-enrolled in life-saving, pain-killing health insurance.  God Help Us.

Sunday, December 8, 2013

Horrible but Secret Processing Delays of Obamacare Paper Apps: HHS should tell the truth

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.
Here are links to some of the reports and other proof that HHS is greatly de-emphasizing the use of paper apps. 
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.  
 
 
 
 
 
Below are expamples of changes made by HHS to steer helpers and customers away from paper applications.
 
 Latest instructions to Obamacare application helpers do not include a paper application as an option (See Links 1, 2, 3, and 4 below).  By this omission of instructions about paper apps, CMS is saying that paper apps are no longer an option AND SHOULD NOT BE USED..  HAS HHS/CMS ADMITTED TO THE PRESS OR THE PUBLIC THAT THERE ARE  SEVERE SOFTWARE PROBLEMS THAT PREVENT THEM FROM MAILING SUBSIDY DECISION LETTERS TO CITIZENS SO THEY CAN CHOSE A QHP (QUALIFIED HEALTH PLAN BY 12/23/13 IN ORDER TO HAVE COVERAGE EFFECTIVE 1/1/14?  I PERSONALLY KNOW ONE PERSONS WHO ENDED UP IN THE EMERGENCY DUE TO DEHYDRATION FROM COLD/FLU SYMTOMS AND SOMEONE WITH A POSSIBLE ABCESSED TOOTH AND HAS MEDICAID BUT WITH A $450/MONTHLY DEDUCTIBLE AND WHO HAD THEIR FOODSTAMPS REDUCED.  BECAUSE OF THE INCOMPETENCE OF HHS/CMS AND THEIR CONTRACTORS, I AM SURE THERE ARE THOUSANDS OF CITIZENS ACROSS THE NATION THAT WILL NEED MEDICAL CARE IN JANUARY 2014, BUT MAY SLIP TOWARD BANKRUPTCY OR SEVERE WORSENING OF THEIR ALREADY DANGEROUS MEDICAL CONDITION, INCLUDING DIABETES, HEART CONDITIONS, SEIZURES, THE FLU, INJURIES, PREGNANCY COMPLICATION, ETC.  SEE THE FIRST POST ON THIS BLOG FOR THE REGULATIONS THAT PERMIT OBAMACARE APPLICANTS THE RIGHT TO APPEAL THE START DATE FOR INSURANCE COVERAGE AND/OR THE FACT THAT THEIR ELIGIBLITY NOTICE WAS DELAYED, TO OMSBUDSMEN OR THE GOVERNMENT AND THAT PERMITS HHS TO CHANGE THE STARTING DATE OF COVERAGE IF DELAYS RESULT FROM THEIR INACTION OR ERRORS BY THE GOVERNMENT OR THEIR CONTRACTORS. (TITLE 45 CFR §155.420   Special enrollment periods)
LINK 1:
 
It Is locate on this page:
 
Link 2 : until
 
It is found under link titled : /tips for helping consumers enroll at the bottom of this page:
 
LINK 3 (Below is the page you get if you press the button titled :Individuals and Families" on the Home page.  It displays only two buttons that read "Apply Online" and "Apply by Phone" 
 
 
Again CMS/HHS is telling customers and staff not to file a paper app.  Why can't they be honest about the delays in sending out decision letters for apps.  This fact has been shared verbally on an internal basis.  They should be honest and tell the press and the public.  I wonder if the President knows?  Until recently he has encouraged people to file by paper too if they wanted to.  The behavior and scenario explains why he didn't know how poorly the website and other software were designed until after their launch.  Come January, the WH may not be the Grinch who stole Christmas but it may be the Grinch who stole help and hope from those who are suffering and those who are ill.
The Grinch puzzled and puzzled...till his puzzler was sore.
Then the Grinch thought of something he hadn't before.
Maybe Christmas-he thought--doesn't come from a store.
Maybe Christmas...perhaps...means a little bit more.
Help me! I'm...feeling HONEST?
And what happened then--Well, in Whoville they say...that the Grinch's
small heart grew three sizes that day
but he still had no insurance
due to a government delay!
 
LINK 4 Archive copy of www.healthcare.gov home page as of 11/7/13 - There is a large graphic in the middle of the page that talks about the four ways to get coverage, which includes paper applications.
 
Here is an archived copy of the home page around 2:30 AM on 12/2 where the large graphic list the 4 ways to file had been removed.
 
This the day after the tip sheets for application helpers were issued as referred to above and it is also the same day that the operation progress report was released:
Even though the halting of paper application process is a software problem it is not mentioned in the report. When the primary parachute failed to open properly (healthcare.gov) as planned in October, HHS and the WH have reminded the public for two months that they can file paper applications (the back-up chute).  It is a horrific feeling to realize that the back-up chute did not open either.  We all know it will not be a soft landing.  One thing that would help would be to be honest about the paper app delay.  For thousands of Americans this will bee a matter of life and death just like a faulty parachute.
  
**********************************************************************

https://www.healthcare.gov/
The primary heading on the home page reads, "Enroll by Dec. 23 for coverage starting as soon as Jan. 1." 
The heading should also include a large disclaimer explaining that individuals and families must file second app after subsidy decision is made, which could take several weeks..
 
Paper App Instructions state:
"Mail your original, signed application (and appendices, if applicable) to: Health Insurance Marketplace Dept. of Health and Human Services 465 Industrial Blvd. London, KY 40750-0001 When you mail your application, be sure to use the correct amount of postage. The postage rate will depend on the weight of your application, which will be based on the number of pages you’ve included. If you don’t have all the information or you can’t finish all the items, send in your application anyway. We’ll follow up with you within 1–2 weeks.
Next Steps You’ll get information on how to enroll in a plan (if you’re eligible) when you get your eligibility results.

New Obamacare Directive May Cause Bigger PR Problem than a Crappy Website: Have Obamacare Workers Been Told Not to Take Anymore Paper Applications?

Every government benefit program I have worked with at SSA and HHS based the beginning eligibility month on the date filed not the date processed. Citizens should not be disadvantaged by the government's inability to process applications. 
On 12/4/13, HHS actually claimed that the backlog of paper applications that mounted in October has now been cleared.
On 12/5/13, two sources at the national level told me that HHS/CMS has made progress on data entry of the paper applications and they just started trying to contact applicants to resolve missing or discrepant entries.  I thought they would have started this over a month ago.  It usually takes SSA 4 to 6 weeks to work this kind of workload.  They believe that customers who asked to received their decision letters by email are getting them in some cases.  However, their system for mailing paper decision letters by regular mail has so many problems that it is kind of at a standstill.  I talked to one Obamacare Application Helper who has only been able to enroll 3 families online since October 1.  The rest they had to resort to paper application.
 
I suggest that anyone filing a paper application:
    1.  should make a complete copy of it
    2. and send it by certified mail. 
    3. They should then call the 800# in 5 to 6 days to verify whether it was received and/or processed.
    4. Then file an appeal  or contact the Omsbudsman before 12/23/13 if they have not received a decision on their subsidy. 

Here is the link to the newest tip sheet for navigators and application helpers:  http://marketplace.cms.gov/help-us/assister-tips-template.pdf
Item III states:
NOTE: for the paper scenario – a consumer MUST select a plan by December 23rd in order to be guaranteed the ability to enroll in a plan with coverage beginning on January 1st, 2014. The consumer should mail in the application allowing ample time for processing of the application and the sending of the paper eligibility determination notice.  We highly recommend whenever possible that you assist the consumer using the online application tool in order to ensure the consumer is able to complete the entire process and select a plan before December 23rd.
 
Another Obamacare worker told me that someone up the line told them that helpers should discourage and basically stop using of paper applications. 
 
I can understand that spokesman for HHS/CMS are following the company line when they say they have not told people to stop using paper apps.  I was an office manager at Social Security for 20 years and when we were on the verge of furloughs or shutdowns due to sequester, debt ceiling, or lack of a budget, we had weekly conference calls to discuss how the agency was going to handle the issues.  All management was banned from talking to employees, the union, or journalist about the phone calls and we were all told to put nothing in writing even if was just our notes. 
The problem is that customers that file applications before 12/23/13 should have their filing date protected by navigators and helpers so they can get help in January.  We have hundreds of pages of employee instructions at SSA on how to protect filing dates, (see the link below)  SSA has been the subject of class action suits in the past and had to rework many many cases.  There were a half million cases called the Special Disability Workload that took over a decade to re-work where a person was due 2 types of benefits and we only paid 1 and we had to pay benefits retroactively over many years.  Let me know and I can find Congressional testimony with details.  Many disability claim appeals take a year or two to process and claimant are due retroactive Medicare coverage for several months or years in the past.  We had a procedure called Equitable Relief where the claimant did not have to pay several years of Medicare Premiums. 
 
Here is the home page for SSA employee instructions:
 
SSA employee instructions for protective filing dates:
 
For years I interviewed citizens when they filed for Social Security benefits.  And for years I could not help them when they or other family members needed health insurance unless they qualified for Medicare.  Finally people will get some relief from the burden of living uninsured. 
 
Unfortunately, we are like the lower classes who populated the lower levels of the Titanic.  They had to swim underwater just to get off the ship.  And then when they are finally floating free of the wreckage, they see a what looks like a small life boat.  However, when they swim over to it in a state of exhaustion and exasperation, they realize it is just a large jellyfish (healthcare.gov) and they end up wrapped in its painful tentacles (glitches, delays, and confusion.)

In order to keep Obamacare from crashing, the Administration must take Bold, Decisive, Positive Action.  See a plan posted at http://whitecollargreenspace.blogspot.com/
Only honesty and sincere concern can keep Obamacare from losing the trust and good will of the people.

Obamacare Customers Can File Appeals if They Miss 12/23 Deadline Due to Government Incompetence‏


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.


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§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.


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§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