Carrie - Presentation Appeals

Notice and Appeals:
Medicaid and the
Notice and Appeals
• Question:
• What will eligibility notice and appeals
processes be for MAGI-Medicaid and
Marketplace applicants?
• Answer:
• Recent federal regulations have provided some
information about guidelines for appeals and
notices but we are still at the beginning of
understanding exactly how these processes will
be implemented in Illinois.
MAGI-Medicaid Appeals
• What we know:
• In Illinois, the Marketplace will “assess” eligibility for
MAGI-Medicaid but the state will be making the actual
eligibility determinations.
• These determinations will be provided to applicants in
writing and, for the time being, will be made under
the 45-day decision timeline in the current statute.
• As a result, the state (BAH) will continue to conduct
the fair hearings for those appealing ineligibility
determinations—not the Marketplace.
Medicaid Appeals
• All applications will trigger a written eligibility
• This notice will include appeal rights and process.
• Medicaid appeals must be filed within 60 days of the
• If an applicant is found not eligible for Medicaid on
appeal, the state will inform the Marketplace so that
the applicant will get connected to health insurance
options there. (The exact details of this process are
being worked out now.)
MAGI-Medicaid Appeals:
• Not much substantial change in this process
with the exception of:
– Electronic Notice
• Individuals may opt to receive notices
electronically—this choice must be confirmed by
the agency via regular mail.
– Mailing must explain how to change back to mail
– After electing this choice, all agency
communication can be sent electronically.
• 42 CFR § 435.918
Marketplace Appeals
• Can appeal:
– Initial determination of eligibility,
– Amount of premium tax credit, and
– Level of cost sharing.
• Who adjudicates?
– In Illinois, probably the HHS appeals entity
– Can bring a representative.
• 45 CFR § 155.505 et seq.
Marketplace Appeals
• Notice:
– Timing—when applicant submits and
application AND on notice of eligibility
– Including: explanation of appeal rights;
description of how to request an appeal;
right to represent self or bring a
representative; right to continuing
benefits; fact that change may affect whole
Marketplace Appeals
• Appeals must be accepted by telephone, mail, in person (if possible), via
• Marketplace must assist person in making the appeal if asked; not
interfere with right to make an appeal.
• Time frame: within 90 days of the eligibility determination or timeframe of
Medicaid agency for its appeals.
• Marketplace must send an acknowledgment of the appeal request and if
appeal is not valid explain why and how to cure if possible.
• May be continuing benefits and expedited hearing if applicable.
• There is an informal resolution process.
• See 45 CFR 155.500 et seq.
Appealing Denial of Health Services
• Refer to Office of Consumer Health Insurance
at (877) 527-9431 to file an appeal regarding
the plan coverage
• Contact the state office to appeal Medicaid
• There is a process to expedite appeals if the
person is having a health crisis as a result of
the denial. Should be mentioned at the time
of the appeal.
• For the Marketplace:
– Office of Consumer Health Insurance
(877) 527-9431
• For Medicaid:
– DHS helpline 1-800-843-6154
– Local IDHS Family Community Resource
Center (FCRC)
– HFS 1-800-226-0768

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