a service of the maryland health benefit exchange maryland health benefit exchange: individual...

A service of the Maryland Health Benefit Exchange

Maryland Health Benefit Exchange:Individual Appeals

of Eligibility Determinations

Karen Rohrbaugh, AAG

October 29, 2013

Reasonable Compatibility

Reasonable Compatibility Methods, 42 C.F.R. § 435.952

There are three ways to determine whether what an applicant attests to is reasonably compatible with the data from electronic data sources:

simple income comparison

detailed income comparison

reasonable explanation– Medicaid only

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Simple Income Comparison

If both the attested and electronic income are above the applicable income standard, the individual is income ineligible

If both the attested and electronic income are at or below the applicable income standard, then the individual is determined to be eligible

If the attestation is above the Medicaid standard and the electronic income is below the Medicaid standard, the applicant is ineligible for Medicaid but may still be eligible for an APTC/CSR

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Detailed Income Comparison

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Reasonable Explanation

For Medicaid only, there are times when the attested information will be accepted, without additional verification, if the applicant provides a reasonable explanation, such as:– employment was seasonal– recent unemployment

The Medicaid Verification Plan is located at: http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Eligibility-Verification-Policies/Downloads/Maryland-Verification-Plan-Template-FINAL.pdf

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Inconsistencies, 45 C.F.R. § 155.315(f)

If the information on the application – e.g., residency, income, citizenship status – is still not reasonably compatible with the data from the electronic data sources, or the electronic data is not available, the applicant is notified that the information cannot be verified

MHBE will then contact the applicant to confirm the accuracy of the information submitted and attempt to identify and resolve the cause of the inconsistency

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Inconsistency Period,45 C.F.R. § 155.315(f)

If those efforts to resolve the inconsistency are unsuccessful, MHBE will provide notice to the applicant of the inconsistency

The applicant has 90 days to either present satisfactory documentation or otherwise resolve the inconsistency– The 90 day period may be extended if the applicant

demonstrates that a good faith effort has been made to obtain the required documentation

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Inconsistency Period, 45 C.F.R. § 155.315(f)

During this Inconsistency Period, MHBE gives the applicant the benefit of the doubt and determines eligibility based on the information provided by the applicant

– An APTC will only be provided if the applicant attests that he or she understands that the APTC is subject to reconciliation.

Upon the expiration of the Inconsistency Period, if the applicant’s information cannot be verified, MHBE must:

– determine the applicant’s eligibility based on the info from the data sources

– send the applicant an eligibility determination indicating that MHBE is unable to verify the attestation.

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Reasonable Compatibility Flow

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Eligibility Determinations

Eligibility Determinations, 45 C.F.R. § 155.515 and Interim Procedure .04(A)

All eligibility determinations include:– a statement of the action MHBE intends to take– the specific laws or regulations that support the action– an explanation of the applicant’s appeal rights, and a

description of the procedures to request an appeal– information on the applicant’s right to be represented by

legal counsel or to designate an authorized representative– an explanation of the circumstances under which the

appellant's eligibility may be maintained or reinstated pending the appeal decision

– an explanation that an appeal decision for one household member may result in a change in eligibility for other household members, resulting in a redetermination of eligibility for the affected members

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Medicaid Eligibility Determinations,Interim Procedure .04(B)

Pursuant to Medicaid rules, determinations involving Medicaid must also: – include an explanation of the circumstances under

which assistance is continued if a fair hearing is requested

– to the extent required by law, state that expenses incurred in connection with a fair hearing, such as transportation and baby-sitting costs, shall be paid by DHMH when incurred by the appellant and may be paid when incurred by the appellant's witnesses

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Redeterminations,45 C.F.R. §§ 155.330 and 155.335

In addition to initial eligibility determinations, MHBE will also issue redeterminations

Redeterminations will be done:– annually– during the year for changes in circumstances

• Enrollees are required to report changes in eligibility factors to MHBE within 30 days

– This is particularly important for individuals who are receiving APTC (due to the IRS reconciliation)

• Periodic data searches are conducted to confirm continued eligibility

Inconsistency Period applies to redeterminations as well

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Appeals

Right to Appeal

Section 1411(f) of the ACA guarantees individuals the right to appeal an eligibility determination

45 C.F.R. § 155.535(c) and the Interim Procedures require MHBE to give an appellant an evidentiary hearing

MHBE is delegating these appeals of individual eligibility determinations to OAH pursuant to:– 45 C.F.R. §§ 155.505(c)(1) and 155.110(a)– Ins. § 31-106(a) and (b)– State Govt. § 10-205(a)(1)(ii)– Intergovernmental Cooperation Act of 1968

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Bases of Appeal, 45 C.F.R. §§ 155.505(b) and155.520(b) and Interim Procedures .03(A) and .05(D)

An appellant has 90 days to appeal on the basis that:

there has been an incorrect determination or redetermination of eligibility

e.g.:–enrollment in a QHP–eligibility for Medicaid/MCHP Premium–eligibility for APTC/CSR

MHBE failed to provide timely notice of an eligibility determination or redetermination

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Bases of Appeal, 45 C.F.R. § 155.505(b)(cont.)

Other bases of appeals are being designated to HHS:– Individual exemptions from the minimum

essential coverage requirement– Appeals from an employer as to whether it

provides its employee with minimum essential coverage that is affordable

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Acknowledgement of Appeal, 45 C.F.R. § 155.520(d)(1) and Interim Procedures .05(B) and .11(A)

MHBE will send a daily report to OAH notifying it of new (valid) appeals

OAH will send an acknowledgement to appellant that also includes:– information regarding the appellant’s eligibility while the

appeal is pending– that any APTCs are subject to reconciliation– an FTI Release form

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Federal Tax Information (“FTI”)

One of the items accessed by HIX in making eligibility determinations is FTIThe IRS has very strict guidelines about access to and disclosure of FTI– IRS Publication 1075

Under the IRS’ policy, even saying that information was verified with FTI or through the IRS constitutes a disclosure of FTINo FTI will be viewed by a human being unless an appeal is filed, and then only if a release is signed by all adult members of the household

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FTI Release

Along with the acknowledgement notice, an FTI Release will be sent to the appellant

The IRS prohibits anyone from seeing FTI unless:– an appeal is filed– an FTI release is signed by each adult member of the household

Effects of a signed release:– A member of MHBE’s Appeals & Grievances Unit will be able to access

the FTI used by HIX solely for the purpose of attempting to resolve the appeal

– The FTI can be shared with the appellant– The information can be disclosed to OAH

If the appellant and/or any adult household member(s) refuse to sign the release(s), the FTI used by HIX cannot be viewed by MHBE staff, the appellant, or OAH, and it will not be introduced at the hearing 21

Eligibility Pending Appeal, 45 C.F.R. § 155.525 and Interim Procedures .11 and .12

There is no eligibility pending appeal for initial determinations

On redetermination:–Enrollment in a QHP: eligible pending appeal–Medicaid/MCHP Premium: eligible pending appeal–APTC/CSR: the appellant can accept eligibility pending appeal at the level of eligibility immediately prior to the redetermination

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Postponements, Interim Procedure .05(C)

If the time or location of a hearing is inconvenient, an ALJ shall designate another time or place convenient to the parties if the moving party has sufficient reason for requesting the change

If the appellant is employed during the periods when fair hearings are normally held, the ALJ shall attempt to schedule the hearing so that the appellant will not be required to miss employment

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Hearing Logistics

At least initially, MHBE’s hearings will be added to existing Medicaid dockets

– Hearings will be held at local DSS offices (existing Medicaid hearing locations)

In the future, hearings are also expected to be held at the six regional Connector Entity locations

– Central: HealthCare Access Maryland

• 201 N. Charles Street, 7th Floor, Baltimore

– Capital: Montgomery County Department of Health

• 401 Hungerford Drive, 5th Floor, Rockville

– Southern: Calvert Healthcare Solutions

• 234 Merrimac Court, Prince Frederick 24

Hearing Logistics

– Lower Eastern Shore: Worcester County Health Department in Snow Hill

• 424 West Market Street, Snow Hill• 6040 Public Landing Road, Snow Hill

– Upper Eastern Shore: Seedco, Inc., in Elkton• 216 E. Pulaski Highway, Elkton

– Western: The Door to Healthcare Western Maryland in Columbia

• 7178 Columbia Gateway Drive, Columbia• 8930 Stanford Boulevard, Columbia

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AnneArundel

Howard

Baltimore

St. Mary's

Charles

Allegany Carroll HarfordCecil

Wicomico

Dorchester

Garrett

Frederick

Montgomery

Calvert

Somerset

Kent

Washington

PrinceGeorge’s Caroline

Talbot

QueenAnne’s

Worcester

Baltimore City

= Western

= Central

= Capital

=Southern

=Upper Eastern Shore

=Lower Eastern Shore

Regional Key

AnneArundel

Howard

Baltimore

St. Mary's

Charles

Allegany Carroll HarfordCecil

Wicomico

Dorchester

Garrett

Frederick

Montgomery

Calvert

Somerset

Kent

Washington

PrinceGeorge’s Caroline

Talbot

QueenAnne’s

Worcester

Baltimore City

= Western

= Central

= Capital

=Southern



Regional Key

= Western

= Central

= Capital

=Southern



Regional Key

Six Connector Entity Regions

MHBE’s Appeal Representatives

Initially, each appeal hearing will be attended by two State representatives:– A caseworker from a local office of either the Health

Department or the Department of Social Services– A member of MHBE’s Appeals & Grievances Unit

• Tamara Cannida-Gunter, Manager of the Appeals & Grievances Unit

• Nicole Edge, Appeals & Grievances Coordinator• Wonda Oliver, Appeals & Grievances Coordinator• Lashona Rahman, Appeals & Grievances

Coordinator

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Authorized Representatives, 45 C.F.R. § 155.227 and Interim Procedure .14

Authorized representatives:

are allowed to act on an individual’s behalf during the application, redetermination, and/or appeal, or in carrying out other on-going communications with MHBE

can be authorized to handle all matters with MHBE, or just certain designated functions

must be designated in a signed written document or recorded electronically through the CSC

Other forms of legally binding documentation, such as a power of attorney, are also valid

must maintain the confidentiality of any information provided by MHBE

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Authorized Representatives, 45 C.F.R. § 155.227 and Interim Procedure .14

are responsible for fulfilling all of the functions for which he or she is authorized, to the same extent as the applicant

must comply with applicable State and federal laws concerning conflicts of interest and confidentiality of information

An authorization remains valid until MHBE is notified of its termination

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Informal Resolution, 45 C.F.R. § 155.535(a)

MHBE or its partner agencies will contact the appellant in an attempt to resolve the matters that are on appeal

– This is in addition to the efforts during the inconsistency period

– MHBE’s Appeals & Grievances Unit will monitor the status of informal resolution attempts

The appellant’s right to a hearing is preserved if the appellant remains dissatisfied after the informal resolution process

If the appeal does proceed to hearing, the appellant will not be asked to provide any duplicative information or documentation that he or she previously provided during the application or inconsistency process

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Dismissals, 45 C.F.R. § 155.530

An appeal must be dismissed by OAH if the appellant:

Withdraws the appeal request in writing

Fails to appear at a scheduling hearing without good cause

Fails to submit a valid appeal request

Dies while the appeal is pending– Except for Medicaid, when retroactive benefits are available

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Dismissals, 45 C.F.R. § 155.530 (cont.)

Timely written notice of a dismissal must be sent by OAH to the appellant, including:– the reason for the dismissal– an explanation of the dismissal's effect on the appellant's

eligibility– an explanation of how the appellant may show good cause why

the dismissal should be vacated

A dismissal must be vacated by OAH, and the appeal allowed to proceed, when the appellant makes a written request within 30 days of the notice of dismissal showing good cause why the dismissal should be vacated– If the request is denied, timely written notice of the denial of the

request to vacate must be sent to the appellant32

Appeal Record, 45 C.F.R. §§ 155.500 and 155.550

“Appeal record” means:

– the appeal decision

– all papers filed in the proceeding

– if a hearing was held, the transcript or recording of the hearing testimony

– any exhibits introduced at the hearing

If requested, an appellant must have access to the appeal record at a convenient place and time, subject to the requirements of all applicable Federal and State laws regarding privacy, confidentiality, disclosure, and personally identifiable information

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Pre-Hearing Procedures, 45 C.F.R.§ 155.535(d) and Interim Procedure .06

MHBE will monitor the appeal to ensure that a case summary is prepared and sent to OAH and the appellant at least six days before the hearing

The appellant and MHBE may request the names of all witnesses that the other party intends to call at the fair hearing

The appellant may seek to subpoena any employee of MHBE whose action is being contested or whose testimony may be relevant

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Hearing Procedures, 45 C.F.R. § 155.535(d)and Interim Procedure .07

The appellant must be given the opportunity to:

present documentary evidence

introduce witnesses

establish all relevant facts and circumstances

present an argument without undue interference

question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses

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Attendance at the Hearing, Interim Procedure .10

The ALJ shall permit members of the public to attend the hearing if the appellant waives, in writing, his or her privilege of confidentiality

The ALJ may order the removal of any member of the public whose conduct impedes the orderly progress of the hearing, or recess the hearing until it may proceed in an orderly fashion

If the size of the hearing room is too small to accommodate them, the ALJ may exclude from the hearing any individuals who have not given advance notice of their intention to attend

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Appeals Decisions, 45 C.F.R. §§ 155.535 and 155.545 and Interim Procedure .09(B)

All appeal decisions must:

be issued within 90 days of the date of the appeal request

– If the date of the hearing was postponed at the appellant's request, the 90 day period is tolled by the length of the postponement

be based solely on a de novo review of:

the information used to determine the appellant's eligibility

any additional relevant facts and evidence presented during the course of the appeals process, including at the hearing

the eligibility requirements under 45 C.F.R. § 155.300 et seq.

the Medicaid and MCHP Premium eligibility requirements37

Appeals Decisions, 45 C.F.R. § 155.545 and Interim Procedure .09(A)

Summarize the facts relevant to the appeal

Identify the legal basis, including the regulations that support the decision

State the decision, including a plain language description of the effect of the decision on the appellant's eligibility

State the effective date of the decision

Indicate that the decision is final unless additional review is sought, and provide an explanation of those rights

Can be based on circumstances as of the date of the hearing, even if different than how they were at the time of determination

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Implementation of Appeals Decisions, 45 C.F.R. § 155.545(c) and Interim Procedure .09(C)

Appeals decisions are generally effective:

prospectively, on the first day of the month following the date of the notice of appeal decision

at the option of the appellant, retroactively to the date the incorrect eligibility determination was made

– however, if the appeals decision is based on facts that occurred subsequent to the determination date, then the decision can only be implemented prospectively

for Medicaid, if the decision is adverse to the appellant, it is implemented immediately

An appeal decision triggers a redetermination of the eligibility of household members whose eligibility may be affected by the decision, even if they did not file their own appeal 39

Subsequent Appeals, 45 C.F.R § 155.505and Interim Procedure .09(C)

An appellant may seek further review as follows:

Petition for judicial review by the Circuit Court within 30 days of the decision, State Govt. § 10-222

Appeal to HHS within 30 days of the decision, 45 C.F.R. § 155.505(c)(2)

For Medicaid appeals, the Board of Review appeal rights remain the same for the present time, Health-Gen. § 2-206(c)

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The Future

The Appeals Module

Expected in November, 2013

ALJs will have access to HIX at all of the hearing sites– Phone lines– Data connection

Evidence will be downloaded from HIX– Except FTI

Evidence brought to the hearing by the appellant will be scanned into HIX

Decisions will be uploaded into HIX, which will automatically notify MHBE and its partners of the decision

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Scenarios

Scenario One

Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren makes $38,000 per year.

What coverage is each member of the household eligible for?

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Scenario One

Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren is a salaried employee making $38,000 per year.

STEP 1: Determine Medicaid/MCHP Premium eligibility

For purposes of Medicaid/MCHP Premium eligibility, there are three people in the household; the fact that Lauren does not claim Mitchell as a deduction on her taxes does not affect the household size for Medicaid/MCHP Premium purposes. The applicable monthly FPL is $1,627.50, so the monthly household income of $3,166.67 is at 195% of the FPL, making both Mitchell and Patrick eligible for MCHP. Lauren, however, is not eligible for Medicaid because her income is above the 138% income threshold.

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Scenario One

Lauren is a divorced mother who lives with her two children, Mitchell and Patrick. Her ex-husband, Chris, claims Mitchell on his taxes while Lauren claims Patrick. Lauren makes $38,000 per year.

STEP 2: Determine APTC/CSR eligibility

For purposes of APTC eligibility, Lauren’s household size is two (since she does not claim Mitchell on her taxes). Therefore, the applicable annual FPL is $15,510. Lauren’s annual income is 245% of the FPL, which qualifies her for an APTC.Since her income is below 250% of the FPL, Lauren is also eligible for a CSR if she enrolls in a silver level plan.

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Scenario Two

Deepak is from India. He was lawfully admitted to the U.S. for permanent residence in 2010. He lives alone and works part-time while he goes to school, earning $9,000 year.

What coverage is Deepak eligible for?

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Scenario Two



Even though Deepak’s income is only at 78% of the FPL, he is not eligible for Medicaid because of the five year bar.

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Scenario Two



Even though APTCs are usually not available for someone earning less than 100% of the FPL, because Deepak is a lawfully-present alien ineligible for Medicaid because of his citizenship status, the special exception applies. Therefore, he is eligible for an APTC, as well as a CSR if he enrolls in a silver level plan.

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Scenario Three

Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. He was previously unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters; HIX annualizes that information and therefore calculates that Kurt’s annual income is $28,000 year. Given that the difference between Kurt’s attested income and the income annualized from MABS is more than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee.

What coverage is Kurt eligible for?

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Scenario Three

Kurt worked at an ice cream stand on the boardwalk in Ocean City from April through September. He was previously unemployed for over a year and did not file taxes during that time. In December, Kurt applies online through Maryland Health Connection and attests to an annual income of $14,000. HIX checks the federal hub but there is no FTI available. HIX then checks the State data sources, and MABS shows that Kurt earned $7,000 in each of the last two quarters; HIX annualizes that information and therefore calculates that Kurt’s annual income is $28,000 year. Given that the difference between Kurt’s attested income and the income annualized from MABS is more than 10%, Kurt is asked to explain the discrepancy. He indicates that he is a seasonal employee.

STEP 1: Determine Medicaid eligibility

Because Kurt’s employment is seasonal, HIX’s calculations were not correct. The issue was resolved during the Inconsistency Period and Kurt was determined to be eligible for Medicaid.

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Scenario Four

Carla and Brian are married and expecting their first child. They have a combined annual household income of $47,000 and are both currently enrolled in QHPs and receiving APTCs to help with their medical expenses. Carla hears from a friend that she should update her information with Maryland Health Connection because she may be eligible for more help with her medical costs, which she does.


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Scenario Four



Carla’s unborn child is now counted towards her household size. With a household of three, the household income of $47,000 is now at 241% of the $19,530 FPL. Therefore, Carla meets the Medicaid threshold for pregnant women and is eligible for Medicaid while she is pregnant and for two months after she delivers.

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Scenario Four



With a household size of two, Brian’s household income of $47,000 is at 303% of the applicable FPL, so he remains eligible for an APTC.

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Scenario Four – Part B

Same scenario, except that six months later Carla and Brian’s daughter, Maya, is born. Their household income remains at $47,000 annually.


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Because her mother was receiving Medicaid at the time of her birth, Maya is a deemed newborn and is therefore automatically enrolled in Medicaid for 13 months. Carla remains eligible for Medicaid for 60 days after Maya’s birth. Upon the expiration of that 60 day period, Carla will no longer be eligible for Medicaid as the household income of $47,000 for a family of three is at 241% of the FPL. Brian also remains ineligible for Medicaid for the same reasons.

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With a household income at 241%, Carla and Brian are both eligible for an APTC, as well as a CSR if they enroll in a silver level plan.

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Contact Information

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L. Kristine Hoffman, Assistant Attorney General to MHBE– [email protected]– (410) 547-1279

Sarah Rice, Assistant Attorney General to DHMH– (410) 767-1879– [email protected]

Karen Rohrbaugh, Assistant Attorney General to MHBE– [email protected]– (410) 547-7379

APPENDIX: Key Terms

Key Terms

Advance Payments of Premium Tax Credit (“APTC”): a refundable tax credit that is available to qualified individuals to help with the cost of purchasing health care coverage through Maryland Health ConnectionCost-Sharing Reduction (“CSR”): A discount that lowers the amount an eligible insured has to pay out-of-pocket for deductibles, co-insurance, and co-payments for plans purchased through MHBEFederal Hub: a data center maintained by the U.S. Department of Health & Human Services (“HHS”) that allows MHBE to verify information through the Social Security Administration, the Internal Revenue Service, the Department of Homeland Security, and HHS

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Key Terms

Federal Tax Information (“FTI”): includes, but is not limited to, tax returns or any information provided to the MHBE by the IRS that relates to a taxpayer’s name, address, identification number, or dependents’ names; the potential liability of any person for any tax or tax-related obligation or offense; and whether a return was filed and/or is subject to audit, investigation, or collection

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Key Terms

HIX: MHBE’s electronic data system which determines eligibility for enrollment in a qualified health plan and for insurance affordability programs

Insurance Affordability Program (“IAP”): a program that makes insurance more affordable for qualified individuals, including Medicaid, MCHP Premium, APTCs, and CSRs.

MAGI-Based Income: A methodology for computing income based on the IRS rules for Modified Adjusted Gross Income, as defined in 26 U.S.C. § 36B(d)(2)

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Key Terms

Maryland Health Connection (“MHC”): the public face of MHBE, www.MarylandHealthConnection.govQualified Health Plan (“QHP”): an insurance plan that is certified by MHBE pursuant to Ins. § 31-115 and is available to qualified individuals through Maryland Health Connection. To be a QHP, a plan must follow established limits on cost-sharing and provide at least the statutorily-designated essential health benefits required in Ins. § 31-116State data sources: both DLLR’s quarterly wage information through the Maryland Automated Benefits System (“MABS”) and DHMH/DHR benefit data

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a service of the maryland health benefit exchange maryland health benefit exchange: individual...

Documents

electronic income

income ineligible

inconsistency period

reasonable compatibility

applicable income standard

electronic data sources

medicaid verification

medicaid standard