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MMAI: ILLINOIS UNIFIED MEDICARE-MEDICAID APPEALS PROCESS August 19, 2014.

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Presentation on theme: "MMAI: ILLINOIS UNIFIED MEDICARE-MEDICAID APPEALS PROCESS August 19, 2014."— Presentation transcript:

1 MMAI: ILLINOIS UNIFIED MEDICARE-MEDICAID APPEALS PROCESS August 19, 2014

2 Presenter Information  Department of Healthcare and Family Services, Office of General Counsel  Ryan Tyrrell Lipinski, Bureau Chief and Chief Administrative Law Judge 2

3 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 3

4 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  MMAI Documents:  Memorandum of Understanding  MMAI 3-way Contract  Chapter 9 Member Handbook Insert  Process Flowchart 4

5 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 5

6 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. 6

7 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 7

8 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

9 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 , 406 9

10 PART 1: GRIEVANCE PROCEDURES

11 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 limit Can be filed with Provider or MCO  External Grievance Filing: Enrollees may call 800-Medicare and MCOs will display link on their site 11

12 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 12

13 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

14 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 14

15 PART 2: APPEALS FOR ENROLLEES

16 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 16

17 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 17

18 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 18

19 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 19

20 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. 20

21 SB ILCS 5/5F-32 new  Pursuant to Public Act 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. 21

22 SB 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. 22

23 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 23

24 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 24

25 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 25

26 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 26

27 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 27

28 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). 28

29 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 29

30 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 30

31 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, , fax or write to us  DHS  HFS  Include a copy of previous level notices 31

32 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 32

33 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 33

34 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

35 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 State See 42 CFR

36 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. 36

37 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 37

38 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 38

39 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. §§ and

40 Questions? 40


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