MMAI: ILLINOIS UNIFIED MEDICARE-MEDICAID APPEALS PROCESS

August 19, 2014

Presenter Information

Department of Healthcare and Family Services, Office of General Counsel Ryan Tyrrell Lipinski, Bureau Chief and Chief

Administrative Law Judge

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Objective

To provide general overview of Plan responsibilities relating to Grievances and Appeals both at the plan level and at the State Fair Hearing level

To provide reference materials for further information

Answer any questions

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Resources governing Appeals and Grievances Federal Regulations governing appeals and grievances: 42 CFR

422, 423, 431 and 438 State Law: Public Aid Code, 305 ILCS 5/11-8 and 305 ILCS 5/11-

11(a)(8) State Law: Managed Care Reform and Patients Right Act, 215 ILCS

134/10, 45, and 50 State regulations:

Fair Hearings, 89 Ill. Adm. Code 104 Managed Care Reform and Patients Right Act, 50 Ill. Adm. Code

5420.70-80 MMAI Documents:

Memorandum of Understanding MMAI 3-way Contract Chapter 9 Member Handbook Insert Process Flowchart

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Commonly Used Terms/Phrases State Fair Hearing

(SFH)=Appeal=Administrative Hearing Client=Recipient=Beneficiary=Appellant

=Grievant=Enrollee=Member=Participant=N.H. Resident

Hearing Officer=Administrative Law Judge

Grievance=Complaint

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MMAI Grievance and Appeal Process U.S. Department of Health and Human

Services Centers for Medicare & Medicaid Services, the Illinois Department of Healthcare and Family Services and eight Managed Care plans have established an integrated and unified system of appeals for Enrollees.

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MMAI Grievance and Appeal Process Huge shift from Fee-For-Service environment Goal=“Bene-Friendly” Increased communication Streamlined approach Enrollees will have reasons for denials/changes

explained to them early on Formal grievance process will provide avenue for

Enrollees to complain about mistreatment MCOs will provide Enrollee’s with reasonable

assistance for completing forms and interpreter services

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Grievance vs. Appeal 8

MCOs participating in the MMAI project will have a formally structured Grievance system and a formally structured Appeal system

Important to distinguish difference between a Grievance and an Appeal

Grievance vs. Appeal

Any complaint that is not an appeal of an action

Can be against Provider or MCO

Examples: Customer service

representative unkind Quality of care Doctor-patient

interaction/rudeness Failure to respect

patient/employee rights

Only Actions can be appealed

Actions are: Denial of service or

payment of service Denial, termination,

reduction in previously authorized service

Failure to provide timely service or a timely appeal

Grievance (Does not come to State Fair Hearings)

Appeal (gives right to a hearing at State level)

See 42 CFR 438.400, 406

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PART 1: GRIEVANCE PROCEDURES

Grievance Process

Enrollee may appoint an Authorized Representative for this process.

Internal Grievance Filing:May be filed at any time

If Medicare only service, 60 day limitCan be filed with Provider or MCO

External Grievance Filing: Enrollees may call 800-Medicare and

MCOs will display link on their site

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Grievance Process

Internal Grievance Process Informal review: MCO will attempt to

resolve Grievances informally Formal review: For grievances not

appropriate for informal review, or denied at the informal level, will be heard by the MCO’s Grievance Committee

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Grievance Committee

Established by the MCO Must have one Enrollee on the committee HFS may require that the MCO has one HFS

representative on the committee Cannot have an individual involved in

previous level of review on the committee Will have health care professionals with

clinical expertise in treating Enrollee’s condition or disease on the committee, if grievance involves clinical issues

See 42 CFR 438.406

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Grievance Process

MCO will respond, orally or in writing, to each Enrollee Grievance within a reasonable time, but no later than 30 days after receipt of the Grievance

No further appeal or hearing rights with State Fair Hearings for grievances

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PART 2: APPEALS FOR ENROLLEES

Appeal Process

3 tracks for Appeals Medicaid-Only Medicaid-Medicare Overlap (home

health, durable medical equipment and skilled therapies)

Medicare-Only Enrollees may access existing Part

D Appeals process for Part D appeals

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All Appeals-Level 1

MCO must give advance notice of any Adverse Action to Enrollee in form titled “Notice of Adverse Action” Notice must be given 10 days prior to Action Notice will provide instructions on how to file an

appeal

All appeals must be filed, orally or in writing, initially with the MCO and within 60 calendar days following the date of the Notice of Adverse Action

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All Appeals-Level 1

Enrollee may appoint an Authorized Representative for the appeal process

Must be in writing Authorized Representatives include:

Guardians Caretaker relatives Providers Attorneys Conservators

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Continuation of Benefits Level 1

Continuation of Benefits For Medicaid services, an Enrollee may continue benefits

during a pending appeal if: The action is appealed within 10 days of MCO Notice of

Action The Enrollee requests the continuation of benefits

For Medicare and Medicare-Medicaid overlap services, the MMAI plan continue benefits pending the Level 1 appeal.

A Enrollee may be held responsible for the cost of benefits if the SFH upholds the MCO’s Appeal Decision, they will be given this warning at the time they opt to continue benefits

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All Appeals-Level 1

Standard Processing Timeframe: 15 business days May extend timeframe by 14 calendar days if

it’s in the Enrollee’s interest, need permission from State Hearings Office

Expedited Processing Timeframe: 24 hours to inform Enrollee of what information is required; then decision must be made in 24 hours after receipt of required information.

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SB 741 -- 305 ILCS 5/5F-32 new

Pursuant to Public Act 98-0651 signed into law on June 16, 2014, all MMAI Managed Care Organizations must allow a nursing home resident’s physician or provider to utilize the MCO expedited appeal process for non-emergency situations when the resident’s physician orders a service, treatment, or test that is not approved by the MCO. 

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SB 741 -- 305 ILCS 5/5F-32 new

All MCOs must have a method of receiving prior approval requests 24 hours a day, 7 days a week, 365 days a year for nursing home residents.

If the MCO’s response is not provided within 24 hours of the provider’s request and the nursing home is required by regulation to provide a service because a physician ordered it, the MCO must pay for the service if it is a covered service under the MCO's contract in the MMAI Demonstration Project, provided that the request is consistent with the policies and procedures of the MCO.

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All Appeals-Level 1

During an appeal, the Enrollee and/or representative is afforded: A reasonable opportunity to present

evidence, allegations of fact and law in person as well as in writing

An opportunity, before and during the appeal, to review his or her case file

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All Appeals-Level 1

MCO will ensure that decision makers for appeal were not involved in previous levels of review and are health professionals with clinical expertise in treating the Enrollee’s condition or disease if: Appeal is denial of medical necessity Clinical Issues

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All Appeals-Level 1

Disposition of Level 1 Appeal will be in the form of Decision Notice

Level 2 will depend on whether the Appeal is: Medicaid-Only Medicare-Medicaid Overlap Medicare-Only

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Level 2 Medicaid-Only

If Enrollee still wishes to appeal after Level 1, they have options: File a request for an appeal with the appropriate

State Fair Hearing Office within 30 calendar days from date of Decision Notice; and, or, Decision Notice will inform Enrollee which State

Hearing Office File a request for a review by an Medicaid

Independent Review Entity within 30 calendar days from date of Decision Notice No right to IRE for Waiver program appeals

To file requests with both SFH and IRE

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Level 2 Medicare-Medicaid Overlap

If the resolution following the Level 1 appeal at the MCO is not in Enrollee’s favor, the Appeal will be automatically be forwarded to the Medicare IRE

Benefits will continue during pendency of IRE review

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Level 3 Medicare-Medicaid Overlap

If the resolution following the Level 2 appeal at the IRE is not in Enrollee’s favor, Enrollee can choose to file for a State Fair Hearing at the appropriate State Hearing Office or the Enrollee can appeal to a Medicare Administrative Law Judge if the amount if the amount in controversy met ($140 in 2014).

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Which Agency Handles my Appeal?

Medicaid Application eligibility including long term care, CAU (disability,) MAGI/ACA appeals

SNAP (Food Stamp) Administrative Disqualification Hearing

(ADH) Mental Health (MH)/Division of

Alcoholism and Substance Abuse (DASA)

Child care Waivers

DRS/HSP (Persons with Disabilities, Persons with HIV/AIDs, Traumatic Brain Injury (TBI)

TANF

Medical items/services Dental Pharmacy Transportation

Child Support Bureau of AllKids determinations Waivers

Developmental Disability (DD) Medically Fragile Technologically

Dependent Children Supportive Living Facilities (SLF) Dept of Aging (DOA)

DHS HFS

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Which Agency Handles “Managed Care Appeals”?

Answer: BOTH!

HSP/DRS Appeals when MCO make service/items level changes Mental Health, behavioral health services and prescription drugs/DASA Managed Care Appeals when Plan makes service/item denials

Medical item or service appeals, including pharmacy, transportation, nursing hour reductions, durable medical equipment

Aging Waiver also known as Community Care Program appeals

DHS HFS

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Medicaid-Only Level 2 and Overlap Level 3

Requesting a State Fair Hearing Medicaid-Only: Information will be included

on MCO Appeal Decision Notice Overlap: Information will be included on IRE

decision Call, email, fax or write to us

DHS HFS

Include a copy of previous level notices

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Continuation of Benefits for State Fair Hearing Level 2 and Overlap

Level 3 Continuation of Benefits

A Enrollee may continue benefits during a pending appeal if: The action is appealed within 10 days of MCO

Notice of Action or the Appeal Decision Notice The Enrollee requests the continuation of benefits

A Enrollee may be held responsible for the cost of benefits if the SFH upholds the MCO’s Appeal Decision, they will be given this warning at the time they opt to continue benefits

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Level 2 Medicaid-Only/ Level 3 Overlap

Enrollee will receive acknowledgment letter and scheduling letter Default: phone

Evidence Shall be sent to State Hearing Office and other party

at least 3 business days prior to hearing Parties may present witnesses or documents to

support case Rules of evidence are relaxed

Hearing is digitally recorded but not transcribed Withdrawals-must be in writing or on the record

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Level 2 Medicaid-Only/ Level 3 Overlap

Decision Timeframes Standard: A Final Administrative

Decision (FAD) is required to be issued within 90 days, beginning when the initial MCO appeal was filed and not counting Enrollee delay

Expedited: 3 business days after the Enrollee files a request for an expedited SFH

See 42 CFR 431.244

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Level 2 Medicaid-Only/ Level 3 Overlap

State Fair Hearing Final Administrative Decision Will be sent to all interested parties

Effectuation of Reversed Appeal Decision If services are not being provided while appeal

pending After reversing the denial of services, the MCO

must render promptly and as expeditiously as health care condition requires

If services are being provided while appeal pending A reversal of a denial must be followed by MCO

Implementation is monitored by StateSee 42 CFR 438.424

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Level 3 Medicaid-Only/ Level 4 Overlap

If State Final Administrative Decision is not wholly in favor of the Enrollee, Enrollee can appeal to State Circuit Court for Administrative Review

Under administrative review law, timeframe to file may be as short as 35 days.

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Medicare A&B-Only

Level 1: Internal MCO appeal, same parameters as others

Level 2: If not fully in favor of Enrollee, auto-forwarded to Independent Review Entity.

Level 3: Medicare Administrative Law Judge (must meet minimum dollar amount and file w/in 60 days)

Level 4: Medicare Appeals Council Level 5: Federal District Court

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Medicare Part D (unchanged) Level 1: Internal MCO appeal. Decision

required in 7 days. Level 2: Appeal to Independent Review

Entity (not automatic). Decision required in 7 days.

Level 3: Medicare Administrative Law Judge (must meet minimum dollar amount and file w/in 60 days)

Level 4: Medicare Appeals Council Level 5: Federal District Court

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Other Medicare Appeal Rights Medicare Quality Improvement

Organization (QIO) Appeal Rights The plan must comply with the termination

of services notice and appeal requirements for Enrollees receiving services from a hospital, comprehensive outpatient rehabilitation facility, skilled nursing facility, or home health agency, consistent with 42 C.F.R. §§422.624 and 422.626.

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Questions? 40