Health Reform WK-EDGE CMS recommends structure, coordination for exchange-related appeals process
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Monday, June 4, 2018

CMS recommends structure, coordination for exchange-related appeals process

By Rebecca Mayo, J.D.

States that have elected for the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) Federally-facilitated Exchange (FFE) to make an assessment of eligibility for Medicaid and the Children’s Health Insurance Program (CHIP) may face distinct issues in coordinating appeals among programs. CMS issued a bulletin in an effort to provide technical assistance related to coordination between HHS appeals entities and Medicaid and CHIP agencies in those assessment states. The states and the HHS appeals entity each have different responsibilities, and the bulletin seeks to clarify how best to fulfill those responsibilities without duplicating the efforts of the HHS appeals entity, state agency or the applicant (CMCS Informational Bulletin, May 22, 2018).

Process. The HHS appeals entity has provided a Memorandum Agreement (MOA) to each state agency in an assessment state which will govern the relationship between the state agency and the HHS appeals agency. The state agency must enter into an agreement with the HHS appeals entity to achieve the necessary coordination. The state agency must also establish a secure electronic interface to transfer accounts, and other information relevant to conducting an appeal, between the state agency and the HHS appeals entity. Finally, once the appeal has concluded, the state agency must notify the FFE of the final Medicaid or CHIP eligibility determination through a secure electronic interface.

Appeal. An exchange-related appeals is an appeal of a determination by the FFE related to an individual’s eligibility for enrollment in a Qualified Health Plan (QHP) through the exchange and, if applicable, for advance payments of the premium tax credit (APTC) and cost-sharing reductions (CSR). In conducting an Exchange-related appeal, the HHS appeals entity may determine the individual to be eligible for Medicaid or CHIP, contrary to the initial assessment of determination. If HHS appeals entity determines that an applicant is eligibility for Medicaid or CHIP, the FFE will automatically trigger an account transfer (AT). The HHS appeals entity will then issue the appeal decision, collect the appeal record, and transmit to the state agency via an electronic file transfer (EFT). Once the state receives EFT it must match it to the AT and determine what additional action is needed.

Accept determination. If the state has elected to accept HHS appeals entity decisions as a final determination, the agency does not need to make its own determination; it need only begin furnishing coverage. The state may choose to make the eligibility for applicants approved for Medicaid effective as of either the date of the individual’s application or the first day of the month of the application. Retroactive eligibility for up to three months prior to the month of application is also required if the individual incurred medical expenses that would have been covered during that period had he or she applied. The effective date of coverage in CHIP may be based on the date of application or a date based on the state’s CHIP state plan.

Assessment. If the state has elected to treat the HHS appeals entity decision as an assessment of eligibility, the agency must accept any finding related to a specific criterion of eligibility made by the FFE or HHS appeals entity without further verification so long as such finding was made in accordance with the state agency’s policies. The state may not request information or documentation from the individual which is already included in the individual’s electronic account or contained in the EFT. The state must then use the information contained in the AT and EFT to make a final determination and must take into consideration any documentary evidence included in the EFT.

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