Marketplace Eligibility Appeals Training for Community Assisters

Cynthia Moreno Diane Ross Sharon Graham

Office of Marketplace Eligibility Appeals

January 10, 2014

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Agenda

1. Appeals Overview - Diane

a. What is an appeal?

b. Types of appeals

c. How to appeal

d. Federal Appeal Entity

e. Appeal process

2. Appeal Forms in Depth - Sharon

3. FAQs - Cindy

4. Round Robin/Qs & As

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What are Marketplace Eligibility Appeals?

An appeal is a request for the Marketplace to review a decision about what an applicant is eligible for.

(All applicants in the individual market Marketplace can eventually appeal their eligibility determination to the federal appeals entity; some state-based Marketplaces provide an additional level of appeal before the federal entity process.)

3 Categories of Appeals: • Eligibility for Marketplace coverage

• Eligibility for Insurance Affordability Programs

• Eligibility for an exemption for the individual responsibility requirement

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Appealing an Eligibility Determination

After receiving an initial eligibility determination (or in future years a redetermination from the Marketplace), a consumer can appeal that determination. The reasons for an appeal vary for Individual, Employer, and Small Business Health Options Program (SHOP) consumers.

Appeal Type Appeal Reason

Individual • Eligibility to purchase a QHP through the Marketplace. • Eligibility for an exemption from the individual responsibility

requirement • Eligibility for APTC (and amount) • Eligibility for CSR (and amount) • Eligibility for CHIP • Eligibility for Medicaid • Eligibility for special enrollment period • Eligibility to purchase catastrophic QHP through the Marketplace • Failure to provide timely notice of an eligibility determination

SHOP • Employer eligibility to participate in the SHOP. • Employee eligibility to participate in the SHOP.

Employer • Potential employer penalty (will NOT apply until 2015). 4

Appeals Information on HealthCare.gov website

https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/

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Ways a Consumer can Appeal

The consumer can file an appeal three ways.

1) Log into their “My Account” at HealthCare.gov/marketplace/individual)

2) Write a letter to Health Insurance Marketplace, 465 Industrial Blvd., London, KY 40750-0061

3) Mail in the appropriate appeal request form, which can be found at https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/.

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Appeal Forms

• Appeal Request Forms are available on Healthcare.gov: https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/

• Three forms: (the last two categories use the same form). Use the form for your

state regardless of whether the consumer is appealing Medicaid, CHIP or a QHP.

– For states that delegate Medicaid & CHIP appeals

– For states that delegate only Medicaid appeals

– For states after the consumer has used up all eligibility rights with their state

– For all other states

• Form must be mailed. It cannot be completed and submitted online this year.

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Federal Appeals Entity

• Office of Marketplace Eligibility Appeals (OMEA)

• OMEA hears appeals and makes decisions on:

– FFM appeals

– SBM appeals after exhaustion of any SBM appeals process, or if no SBM appeals process is available.

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Federal Appeals Entity – Appeals Staff

a. Hearing Officers • Federal employees

• Conduct hearings

• Issue hearing decisions

b. Eligibility Appeals Operations Support Contractor – Maximus Federal Services Operates subject to federal oversight

• Handle intake of appeals

• Determine appeal validity

• Coordinate with states (FFM and SBM)

• Establish case files

• Schedule hearings

• Informal resolution

• Communicate informal resolution and hearing decisions

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Eligibility Appeals Process

The first phase in the appeals process is Appeal Initiation. During this phase:

A consumer or employer completes and sends an appeal request to the Office of Marketplace Eligibility Appeals regarding an eligibility determination with which he or she disagrees.

The appeals request form is posted on HealthCare.gov at https://www.healthcare.gov/can-i-appeal-a-marketplace-decision/

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Eligibility Appeals Process (continued)

The second phase in the appeals process is Informal Resolution and Pre-Hearing Support. During this phase: The appeal request is evaluated to ensure that it is valid and complete. An informal resolution is rendered based on a review of the appeal case. The consumer or person submitting the appeal may request a hearing if they

remain dissatisfied with the informal resolution decision. If the appellant wishes to do so he or she may request additional accommodations such as an interpreter.

The Appeals Worker may contact the appellant to request additional information to determine if the appeal request is valid and complete, request evidence/supporting documentation to make an informal resolution, and/or to reschedule a hearing at the appellant’s request.

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Eligibility Appeals Process (continued)

The third phase in the appeals process is Appeal Hearing/Appeal Resolution. During this phase: An appeal hearing is conducted by phone by a Federal Hearing Officer and a decision is

rendered for Individual appeals. Additional accommodations requested in advance by the appellant will be provided during the hearing.

For Employer and SHOP Appeals evidence and the appeal case are reviewed, and a decision is rendered. There is no hearing.

The Appeals Worker may contact the consumer or person who filed the appeal to request additional information to determine if the Employer and SHOP appeal request is valid and complete, and/or request evidence/supporting documentation to make an appeal decision.

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Eligibility Appeals Process (continued)

The fourth phase in the appeals process is Appeal Closeout. During this phase:

The outcome of the appeal is communicated to the consumer or person requesting the appeal and the Marketplace for effectuation.

State agencies operating programs like Medicaid and CHIP, as necessary.

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Appeal Forms in Depth

• Timeframe to file – 30 - 90 days from the date of the

eligibility determination depending on which organization made the eligibility determination

• Expedited review is possible if need is justified

• Use of form for household

– Signatures and Disclosures

• Designating Authorized Representative

– Appendix C

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Walkthrough of the Appeal Forms

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Walkthrough of the Appeal Forms (cont.)

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Frequently Asked Questions

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