NOTICE OF ACTION (803) and APPEALS - Colorado of Action... · Colorado Department of Public Health...
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NOTICE OF ACTION (803) and APPEALS For Case Managers of HCBS Waivers Presented by: Leila Norden 1 June 2018
Transcript of NOTICE OF ACTION (803) and APPEALS - Colorado of Action... · Colorado Department of Public Health...
NOTICE OF ACTION (803)
and APPEALS
For Case Managers of HCBS Waivers
Presented by: Leila Norden
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June 2018
Our Mission
Improving health care access and
outcomes for the people we serve
while demonstrating sound
stewardship of financial resources
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TOPICS
• Overview of Notice of Action and Appeals
• Recipient Appeals Regulation: 10 CCR 2505-10 8.057
• Process to complete a Notice of Action on BUS
• Overview of appeal process
• Scenarios
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NOTICE OF ACTION / APPEALS
REGULATIONS
As found in Code of Colorado Regulations:
Recipient Appeals: 10 CCR 2505-10 8.057
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CASE MANAGEMENT REGULATIONS
SEPs:
Functions of a Single Entry Point Agency:
10 CCR 2505-10 8.393
CCBs:
Case Management Services:
10 CCR 2505-10 8.607
ULTC 100.2:
Guidelines For Long Term Care Services:
10 CCR 2505-10 8.401.1
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WAIVER REGULATIONS
HCBS-EBD Waiver: 10 CCR 2505-10 8.485
HCBS-DD Waiver: 10 CCR 2505-10 8.500
HCBS-SLS Waiver: 10 CCR 2505-10 8.500.90
HCBS-CES Waiver: 10 CCR 2505-10 8.503
HCBS-CLLI Waiver: 10 CCR 2505-10 8.504
HCBS-CMHS Waiver: 10 CCR 2505-10 8.509
HCBS-SCI Waiver: 10 CCR 2505-10 8.517
HCBS-BI Waiver: 10 CCR 2505-10 8.515.00
CHCBS Waiver: 10 CCR 2505-10 8.506
HCBS-CHRP Waiver: 10 CCR 2505-10 8.508
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DEPARTMENT OF HEALTH CARE
POLICY AND FINANCING PROGRAM
RULES AND REGULATIONS
https://www.colorado.gov/pacific/hcpf/department
-program-rules-and-regulations
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10 CCR 2505-10 8.057
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RECIPIENT
APPEALS
DEFINITIONS
Action: A termination, suspension or reduction of Medicaid,
eligibility or covered services.
Date of Action: The intended date on which a termination,
suspension, reduction, transfer or discharge becomes effective.
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10 CCR 2505-10 8.057
DEFINITIONS (cont’d)Notice: Written statement which contains:
1. A statement of what action the Department or its designee
intends to take
2. The reasons for the intended action
3. The specific regulations that support, or the change in federal
or state law that requires the action
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10 CCR 2505-10 8.057
DEFINITIONS (cont’d)Notice: A written statement which contains (cont’d):
4. An explanation of
a. The individual’s right to request an evidentiary hearing if
one is available
or
b. In cases of an action based on a change in law, the
circumstances under which a hearing will be granted
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10 CCR 2505-10 8.057
DEFINITIONS (cont’d)Notice: A written statement which contains (cont’d):
5. The method by which the individual may obtain a hearing
6. That the individual may represent himself/herself or use legal
counsel, a relative, a friend, or other spokesman at the hearing
7. An explanation of the circumstances under which Medicaid is
continued if a hearing is requested
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10 CCR 2505-10 8.057
DEFINITIONS (cont’d)
Request for a Hearing: A clear expression by the applicant or
recipient, or his/her authorized representative that he/she wants
an opportunity to present his/her case to a reviewing authority.
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10 CCR 2505-10 8.057
ADVANCE NOTICE TIMELINES
Notice must be mailed to recipient at least 10
calendar days before the date of intended action
except as permitted in 10 CCR 2505-10 8.057.2.B
and 10 CCR 2505-10 8.057.2.C
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10 CCR 2505-10 8.057
1.Recipient has died
2.Recipient no longer wishes services
3.Recipient gives information requiring termination
/ reduction of services and understands this is the
result
4.Recipient admitted to institution
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ADVANCE NOTICE TIMELINES (cont’d)
10 CCR 2505-10 8.057
4. Recipient’s whereabouts unknown and no
forwarding address
5. Recipient receives Medicaid services outside of
Colorado
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ADVANCE NOTICE TIMELINES (cont’d)
10 CCR 2505-10 8.057
ADVANCE NOTICE TIMELINES (cont’d)
If the Department or its designee has facts indicating
probable fraud by the recipient and, if possible, has
verified those facts through secondary sources,
notice for any action shall be sent 5 calendar days
before the date of the action.
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10 CCR 2505-10 8.057
OPPORTUNITY FOR HEARINGIndividuals have an opportunity for a hearing when:
• Application for services is denied or is not acted upon with
reasonable promptness
• The recipient requesting the hearing believes the action is
erroneous
NOTE: Individuals will not have the right to an opportunity for
hearing if the sole issue is a federal or state law requiring an
automatic change adversely affecting some or all recipients.
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10 CCR 2505-10 8.057
REQUEST FOR HEARING
Requests are filed with the Office of Administrative Courts
within 60 calendar days of the date of the notice of action
Requests shall be in writing and contain:
Individual’s name, address, and State Identification Number
What is being appealed and why it is being appealed
NOTE: If the recipient or applicant makes an oral request for a
hearing to the Department or its designee, the Department /
designee shall prepare a written request for the individual’s
signature or have the individual prepare such a request
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10 CCR 2505-10 8.057
REMEMBER…• If an individual requests a hearing before the date of the action,
services may not be reduced or terminated until final agency decision
• After date of action, services may be continued/reinstated if request
for hearing is not more than 10 days after the effective date AND
individual provides verification that:
1. Individual’s life, health, or safety will be seriously impacted by loss
of benefits OR
2. Individual unable to request hearing before date of action due to
individual’s disability or employment OR
3. Individual’s caregiver or authorized representative unable to
request a hearing before date of action due to his/her health or
employment OR
4. Individual did not receive the notice prior to the intended action’s
effective date
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10 CCR 2505-10 8.057
REMEMBER…
If the action of the Department / designee is sustained
by the final agency decision, recovery procedures may
be instituted to recoup cost of services received after
the date of the action
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10 CCR 2505-10 8.057
REQUEST FOR HEARING
Individuals/authorized representatives are entitled to
examine complete case files and any other documents
to be used at the hearing at a reasonable time before
the hearing or during the hearing.
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10 CCR 2505-10 8.057
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CASE
MANAGEMENT
AGENCY
CONTRACT
CCB Contract 2018-2019
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1.4.3.1. The Contractor shall represent the Department and defend any adverse
action in accordance with 10 CCR 2505-10, Sections 8.057 et. seq in all appeals
initiated during this Contract. The Contractor shall coordinate with the Department
for any adverse actions necessitating Department attendance at a hearing.
1.4.3.2. The Contractor shall represent its actions at Administrative Law Judge
hearings when the Client appeals a denial or adverse action affecting Client’s
program eligibility or receipt of services.
1.4.3.3. The Contractor shall process appeals in accordance with schedules
published by the State of Colorado Office of Administrative Courts and rules
promulgated by the Department.
1.4.3.4. The Contractor shall submit exceptions when applicable and include all
relevant information.
1.4.3.5. The Contractor shall cooperate with the Office of the State Attorney
General for any case in which it is involved.
CCB Contract 2018-2019 (cont’d)
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1.7. MEDICAID PROGRAMS
1.7.1. Rules, Regulations and References
1.7.1.1. The Contractor shall abide by and perform its duties and obligations in
conformity with relevant federal law, all pertinent federal regulations, State law,
rules and regulations of the Department of Health Care Policy and Financing and the
Colorado Department of Public Health and Environment which include but are not
limited to: Colorado Revised Statute, Title 25.5, Article 10.
1.7.1.2.5 Recipient Appeals, 10 CCR 2505-10, Section 8.507.
SEP Contract 2018-2019
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1.1.17. Eligibility Determination – Eligibility Determination includes, but is not
limited to:
1.1.17.1.1.3. Representing the Department in all appeals relevant to functional
eligibility determinations.
4.1. Contractor’s Obligations
4.1.4.10. Recipient Appeals, 10 CCR 2505-10, Section 8.057
4.2.4. The Contractor shall attend Administrative Law Judge hearings when the
Contractor agency has made a denial or adverse action against a client and the
client appeals. The Contractor shall defend its decision as described in 10 C.C.R.
2505-10, Sections 8.057 et seq.
4.4.1. The Contractor shall perform all eligibility determination functions for the
operation of a SEP agency in accordance with CRS §25.5-6-104 and 10 CCR 2505-10,
8.393.2 et seq., but not limited to the following:
4.4.1.5. Representing the Department in all appeals relevant to a long-term services
and supports program participation.
SEP Contract 2018-2019 (cont’d)
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4.5. Case Management for HCBS Waivers
4.5.1. The Contractor shall provide Medicaid Case Management in accordance with
10 CCR 2505-10, 8.393.2.G et seq. and 10 CCR 2505-10, 8.393.1.M et seq. Case
Management services are comprehensive and shall include but not be limited to:
4.5.1.8. Representing the Department in all appeals relevant to service
authorizations.
4.6. Training, Complaints, Appeals, Critical Incidents, And Administrative
Oversight Requirements
4.6.1. Training:
4.6.1.1. The Contractor shall ensure that all case management staff receive training
within ninety (90) days after the staff member’s hire date prior to being assigned
independent case management duties; all other case management staff must
receive a refresher training as required by the Department or the Contractor.
Training must be in the following areas:
4.6.1.2.5. Notices and Appeals.
SEP Contract 2018-2019 (cont’d)
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4.8. Appeals:
4.8.1. The Contractor shall represent the Department and defend any adverse
action in accordance with 10 CCR 2505-10, Sections 8.057 et. seq in all appeals
initiated during this Contract.
4.8.2. The Contractor shall represent its actions at Administrative Law Judge
hearings when the Client appeals a denial or adverse action affecting Client’s
program eligibility or receipt of services.
4.8.3. The Contractor shall process appeals in accordance with schedules published
by the State of Colorado Office of Administrative Courts and rules promulgated by
the Department.
4.8.4. The Contractor shall submit exceptions when applicable and include all
relevant information.
4.8.5. The Contractor shall cooperate with the Office of the State Attorney General
for any case in which it is involved.
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COMPLETION OF
NOTICE OF ACTION
ON THE BUS
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Case manager discusses with individual that there is either a denial or service
reduction / change and that a Notice of Action will be sent out.
Individual informs case manager of plans to appeal. Individual follows up by
sending Request for Administrative Law Judge Hearing to Office of
Administrative Courts. NOTE: If unsure whether intent to appeal has been
submitted, case managers can contact the Office of Administrative Courts to
see if request has been submitted.
Case manager follows up by completing the Notice of Action (803) on the BUS
and mailing it to the individual.
PROCESS OVERVIEW
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Office of Administrative Courts notifies the Department and Appellee that an
appeal has been filed and a hearing requested. Date of hearing and other
important details provided in the Notice of Hearing.
The judge takes the information presented and makes an Initial Decision.
At the hearing – each side presents their body of evidence and argues their case
before the judge.
PROCESS OVERVIEW (cont’d)
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If party not found in favor disagrees – they can write and file an exception; the
other party can submit a response to exceptions.
Individuals who disagree with Final Agency Decisions can continue the appeal
process beyond the Final Agency Decision.
Final Agency Decision is made by the Department.
PROCESS OVERVIEW (cont’d)
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NOTICE OF ACTION
Mailed 6/1/18
EFFECTIVE DATE: 6/11/18
Appeal submitted 6/8/18
Benefits continue through final
agency decision
Request for hearing submitted
6/15/18
Individual provides evidence that,
due to disability, was unable to
submit appeal prior to the date of
action. Requests reinstatement of
benefits.
Benefits discontinued 6/11/18
Administrative Law Judge
informs the Case Management
Agency to reinstate the benefits
through the duration of the
appeal
SCENARIOS
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SCENARIO #1
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You have just completed a revision to a Service Plan
for an individual on your caseload reducing
Homemaker services and adding Personal Care
services.
Do you send a Notice of Action to the individual?
SCENARIO #2
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In completing a Continued Stay Review (CSR), you
send a PMIP form to the individual’s doctor to
complete and return. The doctor notifies you that
she has not seen the individual in 15 months and will
not complete the form. You inform the individual
and explain that the PMIP is required for services to
continue. He tells you he refuses to go to see his
doctor.
Do you send a Notice of Action to the individual?
SCENARIO #3
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You complete the Intake process for an individual
and determine that he meets Level of Care for the
waiver. However, after submitting the Certification
Pages to the county LTC office, you are informed
that he does not meet financial criteria for Medicaid.
Do you send a Notice of Action to the individual?
SCENARIO #4
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An individual on your caseload is moving to another
county and will be in another Case Management
Agency’s catchment area. You are transferring the
case from your agency and asking the other CMA to
accept the case.
Do you send a Notice of Action to the individual?
SCENARIO #5
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Several months into a service plan year, you are
notified that there is a break in an individual’s
Medicaid eligibility.
Do you send a Notice of Action to the individual?
SUMMARY
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SUMMARY
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Individuals can appeal termination, suspension or
reduction of Medicaid, eligibility or covered services
Case managers must provide a Notice of Action informing
individuals of the action
Case managers must cite correct regulations in the Notice
of Action to ensure accuracy
Case managers must enter the correct dates in the Notice
of Action
QUESTIONS?
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CONTACT INFORMATION
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Victor Robertson
Case Management Specialist
Joelle Morrison
Eligibility Appeals Coordinator
Thank You!
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