Criteria group: Appeals Procedures and Coordination — consolidated representation of all proposed regulatory criteria, options, safeguards, and operational requirements to coordinate appeals among Exchanges, Exchange appeals entities, Medicaid agencies, and CHIP agencies.
Title: Scope and Definitions — Appeals coordination provisions apply to eligibility determinations and redeterminations for enrollment in a QHP, Medicaid, CHIP, and advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSR). Key defined entities include: Exchange, Exchange appeals entity (including State-based Exchange appeals entity and HHS appeals entity), Medicaid agency, CHIP agency, and appeals entity. (See proposed 45 CFR 155.505, and revisions to 42 CFR 431.10.)
Title: Options for Conducting Appeals — Exchanges may establish an internal appeals process or use HHS appeals processes. Final eligibility determinations after exhaustion of inconsistency periods may be appealed through the Exchange appeals process (if established) or to HHS. All Exchange appellants may request HHS review upon exhaustion of the Exchange appeals process. (Proposed §155.505(c)).
Title: Notice of Appeal Procedures — Exchanges must provide notice of appeal procedures at application and again when eligibility determination notices are sent (e.g., §155.310(g), §155.330(e)(1)(ii), §155.335(h)(1)(ii)). Notices must explain appeal rights, procedures to request an appeal, right of representation (including authorized representatives), and whether eligibility may be maintained or reinstated pending appeal. Notices should explain that an appeal decision for one household member may affect others. (Proposed §155.515).
Title: Methods and Timing for Appeal Requests — Appeals entities and Exchanges must accept appeal requests by telephone, mail, in person, or via the Internet. Appellants may request appeals within 90 days of the eligibility determination notice. State-based Exchange appeals entity decisions may be appealed to HHS within 30 days of the decision. Upon receipt of a valid appeal request, the appeals entity must acknowledge timely and notify relevant programs via secure electronic interface. (Proposed §155.520).
Title: Acknowledgement and Initial Processing — On receipt of a valid appeal request, the appeals entity must: (1) send acknowledgement to the appellant including information about eligibility pending appeal and that any APTC paid is subject to reconciliation; (2) send timely notice via secure electronic interface of the appeal request and, if applicable, instructions to provide eligibility pending appeal to the Exchange and Medicaid/CHIP agencies; (3) confirm receipt of records transferred to/from the Exchange; and (4) if an appeal request is invalid, promptly notify the appellant with reasons and opportunity to cure. (Proposed §155.520(d)).
Title: Eligibility Pending Appeal — Appeals entities must specify standards for when eligibility is maintained or reinstated pending appeal, consistent with Medicaid fair hearing protections where applicable. Acknowledgement notices must include instructions and status of coverage pending appeal. (Cross-ref: §155.525 and Medicaid fair hearing rules at 42 CFR part 431 subpart E).
Title: Coordination Agreements and Data Exchange — Appeals entities or Exchanges must enter into agreements with agencies administering insurance affordability programs that: (a) minimize burden on appellants (avoid requesting documentation already in the file unless it cannot be located after careful review); (b) ensure prompt issuance of appeal decisions; and (c) comply with Medicaid coordination requirements at 42 CFR 431.10(d). All appeals-related data exchanges must comply with applicable Exchange data protection, privacy, and interface requirements (§155.260, §155.270, §155.345(h)). (Proposed §155.510(a),(c)).
Title: Medicaid/CHIP-Specific Coordination Standards — (1) Opt-in to Medicaid/CHIP Agency Hearings: Appellants must be informed of the option to opt to pursue an appeal of an adverse Medicaid or CHIP determination directly with the Medicaid or CHIP agency rather than the Exchange appeals entity; if the appellant elects this, the appeals entity must promptly transmit the eligibility determination and all appeal-related information via secure electronic interface to the Medicaid or CHIP agency. (Proposed §155.510(b)(1)). (2) Delegation and Combined Decisions: Where the Medicaid/CHIP agency has delegated appeals authority to the Exchange appeals entity and the appellant elects the Exchange hearing, the appeals entity may include Medicaid/CHIP eligibility determinations in the appeals decision. The appeals entity must apply MAGI-based income standards and citizenship/immigration verification consistent with Medicaid and CHIP rules (42 CFR parts 435 and 457). Notices related to Medicaid/CHIP determinations must meet Exchange and state Medicaid/CHIP standards. (Proposed §155.510(b)(2)). (3) Transmission When No Delegation: If appeals authority was not delegated, the appeals entity must transmit the determination and all appeal information promptly to the Medicaid/CHIP agency. (Proposed §155.510(b)(3)).
Title: Timing of Medicaid Fair Hearing Decision When Exchange Decision Issued — When Exchange appeals entity issues a decision relating to eligibility to enroll in a QHP and for APTC/CSR, and the Medicaid agency has not delegated hearing authority or the appellant opts for a Medicaid hearing at the Medicaid agency, a Medicaid fair hearing decision may be issued within 45 days from the date the Exchange appeals entity issues its decision. This balances timeliness with operational realities. (Proposed §431.244(f)(2)).
Title: Reinstatement and Transfer of Applications upon Appeal — If an individual withdraws a Medicaid application after an Exchange assessment but later files an appeal related to QHP/APTC/CSR determinations and is assessed potentially Medicaid eligible, the Medicaid application would be automatically reinstated effective as of the initial application date, the individual's electronic account transferred to the Medicaid agency, and the Medicaid agency would make a final determination. If denied, the individual can request a Medicaid fair hearing. (Proposed §435.907(h) and §435.1200(d)).
Title: Use of Secure Electronic Interfaces and Limits on Redundant Requests — The secure electronic interfaces between Exchange, Exchange appeals entity, and Medicaid/CHIP must be used to: notify of appeals filed that trigger automatic Medicaid fair hearing requests; transfer electronic accounts and appeals information; and prevent requesting from the appellant documentation already present in the individual's electronic account or provided to the Exchange or Exchange appeals entity. The Medicaid agency must not request documentation already included in the individual's electronic account. (Proposed §435.1200(g)(1)-(2)).
Title: Transmission of Medicaid Fair Hearing Decisions to Exchange — The Medicaid agency must transmit its fair hearing decision to the Exchange in two scenarios: (1) when an individual was initially determined ineligible for Medicaid by the Exchange pursuant to a delegation and the Exchange appeals entity had jurisdiction; and (2) when an individual initially determined ineligible for Medicaid by the Medicaid agency had his or her account transferred to the Exchange and a fair hearing was conducted by the Medicaid agency. This ensures the Exchange can adjust APTC/CSR for enrolled QHP coverage pending the hearing outcome. (Proposed §435.1200(g)(3)).
Title: Oversight, Safeguards, and Written Delegation Agreements — Delegations of Medicaid fair hearing authority to an Exchange must be effectuated through written agreements specifying roles, responsibilities, quality control, reporting requirements, oversight by the Medicaid agency, and assurances that the Exchange will comply with fair hearing requirements in subpart E. Delegation is permitted only to governmental Exchanges that maintain merit protections for employees; delegation to other state agencies is not permitted absent a waiver under the Intergovernmental Cooperation Act (31 U.S.C. 6504). The Medicaid agency must inform individuals they may opt instead for a Medicaid agency hearing when delegation occurs. The Medicaid agency may also elect to review conclusions of law made by the Exchange appeals entity (not factual findings) under a time frame consistent with final decision requirements. (Proposed 42 CFR 431.10(c) and (d)).
Title: Application of MAGI and Verification Standards in Delegated Appeals — Appeals entities adjudicating Medicaid/CHIP eligibility must apply MAGI-based income methodologies and Medicaid/CHIP verification procedures (including citizenship/immigration verification through the Federal Data Services Hub where applicable) consistent with parts 435 and 457. This includes treating determinations of not potentially eligible for Medicaid/CHIP as ineligible for purposes of APTC/CSR. (Proposed §155.510(b)(2)(i) and (b)(4)).
Title: Minimizing Consumer Burden and Duplicate Appeals — To reduce consumer burden, appeals of an Exchange determination of APTC/CSR that also trigger an automatic Medicaid fair hearing will be treated as a request for a Medicaid fair hearing so the appellant does not need to file separate appeals. Exchanges must consider whether a later effective date (e.g., Jan 1, 2015) is appropriate to allow states to operationalize automatic-treatment provisions. (Proposed §431.221(e)).
Title: Data Sharing and Program Integrity — All appeals-related data exchanges must comply with privacy, security, and authentication standards in Exchange regulations (e.g., §155.260), support reconciliation with the IRS as needed, and permit HHS data requests. The agreements between entities must ensure data exchange protocols minimize burden and support prompt decisions. (Proposed §155.510(c) and §155.260/§155.345(h)).