Understanding the Administrative Hearing Process & 2017 Managed Care Regulations Changes
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1 Understanding the Administrative Hearing Process & 2017 Managed Care Regulations Changes Home and Community Based Waiver Conference November 14,
2 OUTLINE I. Purpose of Training II. Purpose of a Hearing III. Right to Hearing for Medicaid Beneficiaries IV. Right to Hearing for Self-Determination? V. Notice of an Action/Adverse Benefit Determination/Notice of Resolution VI. Request for Hearing VII. Preparation for Hearing VIII. The Hearing IX. No Ex Parte (one-sided) Communications X. How to Contact the Michigan Administrative Hearing System (MAHS) Benefits Division XI. New 2017 Managed Care Regulations XII. Questions 2
3 I. PURPOSE OF TRAINING What does the Michigan Administrative Hearing System (MAHS) Benefits Services (DHHS/DCH) Division do? What are the rights of Medicaid beneficiaries; Due Process? An Administrative Hearing What is it? Do Administrative Hearings apply to CMHSP, Healthy Michigan Plan, Integrated Care & Self-Determination? 3
4 II. PURPOSE OF A HEARING Constitutional right of due process Federal Social Security Act and Medicaid Federal Regulations Medicaid an entitlement US Supreme Court Goldberg v Kelly Due Process standards 4
5 III. RIGHT TO A HEARING FOR MEDICAID A. MA Applicants and Beneficiaries Action: Reduction, suspension, termination or denial of Medicaid eligibility or covered service. 42 CFR B. (Managed Care Organization [MCO]/Prepaid Inpatient Health Plan [PIHP]) Under new 2017 managed care regulations Adverse Benefit Determination: The denial or limited authorization of a requested service. The reduction, suspension, or termination of a previously authorized service. The denial, in whole or in part, of payment for a service. The failure to provide services in a timely manner, as defined by the State. The failure of an MCO, PIHP to act within timeframes provided (44 days?). For residents in rural areas with only one MCO, the denial of his or her right to obtain services outside of the network. The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities. 42 CFR (b)-(1) through (7 5
6 III. RIGHT TO A HEARING FOR MEDICAID for MCOs and PIHPs Under the new 2017 managed care regulations Adverse Benefit Determination (ABD) Internal Appeal filed within 60 days ABD upheld and Notice of Resolution issued Exhaustion of Internal Appeal Request for State Fair Hearing within 120 days 42 CFR & 408 6
7 IV. Right to Hearing for Self- Determination? 6. Termination of a Self-Determination Agreement by a PIHP/CMHSP is not a Medicaid Fair Hearings Issue. Only a change, reduction, or termination of Medicaid services can be appealed through the Medicaid Fair Hearings Process, not the use of arrangements that support self-determination to obtain those services. Same for Waiver Programs, i.e., EDW, ICO MDHHS/CMHSP Managed Mental Health Supports and Services Contract FY17 Attachment C3.3.4, Policy Section II.E.5 P 8 7
8 IV. Right to Hearing for Fiscal Intermediary Service? Fiscal Intermediary Services are a Medicaid covered service; denial, reduction termination lend right to hearing N. FISCAL INTERMEDIARY Fiscal Intermediary Services is defined as services that assist the adult beneficiary, or a representative identified in the beneficiary s individual plan of services, to meet the beneficiary s goals of community participation and integration, independence or productivity while controlling his individual budget and choosing staff who will provide the services and supports identified in the IPOS and authorized by the PIHP. MPM, October 1, 2016, version, Behavioral Health and Intellectual and Developmental Disability Supports and Services Chapter, pp
9 Right to Hearing Review Eligibility and service issues which hold a right to administrative hearing Eligibility and service issues which do not hold a right to administrative hearing Grievance vs. administrative hearing Self-Determination Clients responsibilities during the hearing process Self-Determination Providers responsibilities during the hearing process 9
10 Right to Hearing Preview for 2018 HMP Healthy Behaviors referral to Insurance Marketplace? Adult Foster Care placement discharges MI Child? 10
11 Hearing Process Differs Between non-mco and MCO Managed Care Organizations = MCO (includes CMH, MIChoice, Medicaid Health Plan, Healthy Michigan Plan) The Hearing Process Differs depending on whether: 1. You are a MA applicant or non-mco enrollee 2. You are enrolled in an MCO 11
12 NOTICE TO THE BENEFICIARY OF AN ACTION MA Enrollee non-mco I. ADEQUATE NOTICE MUST: 1. Be mailed not later than the date of action; and 2. State what action the Agency intends to take; and 3. State the reason for the intended action; and 4. State the specific regulation(s) that support the proposed action; and 5. Give an explanation of the individual s right to request an evidentiary hearing and how to access it; and 6. State that she may represent herself or use legal counsel, a relative, friend or other spokesperson. 42 CFR
13 NOTICE TO THE BENEFICIARY OF AN ACTION MA Enrollee non-mco (Continued) II. ADVANCE NOTICE MUST: 1. Be mailed at least 10 days before the date of action; and 2. State what action the Agency intends to take; and 3. State the reason for the intended action; and 4. State the specific regulation(s) that support the proposed action; and 5. Give an explanation of the individual s right to request an evidentiary hearing and how to access it; and 6. Give an explanation of the circumstances under which services are continued if a hearing is requested and that the agency may institute recovery procedures; and 7. State that she may represent herself or use legal counsel, a relative, friend or other spokesperson. 13
14 ADVANCE NOTICE OF ACTION - MA Beneficiary Date ADVANCE ACTION NOTICE Name Address City, State, Zip RE: petitioner s Name: petitioner s Medicaid ID Number: Dear : Following a review of the [type of service] services and supports that you are currently receiving, it has been determined that the following service(s) shall be <reduced, terminated or suspended> effective <date>. Service(s) Effective Date The reason for this action is <reason>. The legal basis for this decision is <specific regulation>. If you do not agree with this action, you may request a Medicaid fair hearing within 90 calendar days of the date of this notice. Hearing requests must be made in writing and signed by you or an authorized person. To request a fair hearing, complete the enclosed "Request for Hearing" form, and return it in the enclosed preaddressed envelope, or mail to: MICHIGAN ADMINISTRATIVE HEARING SYSTEM BENEFIT SERVICES DIVISION P.O. BOX LANSING, MICHIGAN
15 ADVANCE ACTION NOTICE MA Beneficiary Page 2 You have a right to an expedited hearing if waiting for the standard time for a hearing would seriously jeopardize your life or health or would jeopardize your ability to attain, maintain, or regain maximum function. To request an expedited hearing, you must call, toll-free, You will continue to receive the affected services until the hearing decision is rendered if your request for a fair hearing is received within 10 days of the date of the notice or prior to the effective date of action. If you continue to receive benefits because you requested a fair hearing you may be required to repay the benefits. This may occur if: -The proposed termination or denial of benefits is upheld in the hearing decision. -You withdraw your hearing request. -You or the person you asked to represent you does not attend the hearing. You may contact the Michigan Administrative Hearing System, toll free, at or the PIHP if you have further questions. Enclosures: Hearing Request Form 15
16 V. NOTICE TO THE ENROLLEE OF AN ADVERSE BENEFIT DETERMINATION-MCO 16
17 V. NOTICE TO THE ENROLLEE OF AN ADVERSE BENEFIT DETERMINATION p. 2 17
18 V. NOTICE TO THE ENROLLEE OF THE ADVERSE BENEFIT DETERMINATION RESULTS-MCO 18
19 V. NOTICE TO THE ENROLLEE OF THE ADVERSE BENEFIT DETERMINATION RESULTS-MCO p.2 19
20 VI. REQUEST FOR HEARING The Medicaid agency or provider may not limit or interfere with applicant s or recipient s freedom to make a request for hearing. Request must be in writing. Request for hearing must not exceed 90 days from date notice of action is mailed. (120 days if applying for/enrolled in Medicaid Managed Care.) 20
21 21
22 22
23 VII. PREPARATION FOR HEARING READ THE APPEAL CONTACT APPROPRIATE WITNESSES PREPARE A HEARING SUMMARY: Define the issue/action taken Determine whether proper notice was sent Research applicable policy Write a short chronological narrative detailing what occurred Include any documents considered as evidence: The Appeal The Notice Medical documentation, if relevant to the action taken Other documents that may have been considered Applicable Policy Number the pages of hearing summary and all attachments Send a copy of the hearing summary and all documents for the judge at the hearing to the Petitioner and Authorized Hearing Representative at least seven (7) days prior to the scheduled hearing date. 23
24 VIII. THE HEARING At the hearing: The Administrative Law Judge (ALJ) will introduce the case and the parties. The ALJ will swear in witnesses. The hearing typically begins with the Department s representative presenting its case. The Department will introduce its hearing summary into the record. The Department will question its witnesses, if any. The MA Beneficiary will have an opportunity to question the Department s witnesses and object to any documents in the hearing summary. The MA Beneficiary will present his/her side of the story. The Department s Representative will have an opportunity to question the MA Beneficiary and his/her witnesses. Both the MA Beneficiary and the Department s Representative may provide a closing statement. Both the MA Beneficiary and the Department s Representative may be asked to provide additional documentation to the ALJ. 24
25 IX. AT THE HEARING - Continued Role of the Administrative Law Judge Conducts complex hearings in accordance with rules of evidence, DCH policy, and state and federal regulations and statutes. Authority for hearings are found in the Mental Health Code, Public Health Code, Social Welfare Act, the Administrative Code, the Admin. Procedures Act, Social Security Act and federal regulations. Reviews case files prior to hearing to identify issues, relevant legal authority, and procedural questions. Administers oaths and affirmations. Maintains order and makes a complete formal record of the proceedings. Regulates participation of parties. Rules on motions, objections, the relevance of testimony and exhibits, offers of proof and other procedural matters, and receives relevant evidence. Questions witnesses if necessary or desirable. Hears arguments of the parties and/or counsel upon completion of presentation of evidence. Receives expert testimony of physicians and other professionals in specialized fields. Reviews cases, issues final decisions and orders, or issues recommended decisions for the Department Director s review. Reviews files, records, and briefs. Performs research on legal and policy questions. Makes findings of fact and determinations of law. Issues final decisions and orders, or recommended decisions. 25
26 IX. EXPARTE COMMUNICATIONS Are Prohibited (Including one-party phone calls & requests for adjournments.) Any document sent to MAHS must be served on opposing party. 26
27 X. HOW TO CONTACT MAHS Benefit Services Division Address: PO Box Lansing, MI Telephone: (517) (877) for Medicaid MA Beneficiary use Facsimile: (517) MAHS Website: To locate Hearings Pamphlet and Forms on DHHS Website Assistance Programs >> Medicaid >> Medicaid Fair Hearings Scroll to bottom of page 27
28 CHANGES TO THE MANAGED CARE REGULATIONS 42 CFR 438 Effective July 1, 2017 for HMP and MGD care application and co-pays/contribution Effective Oct. 1, 2017 for Managed Care Organizations (MCO s) Prepaid Inpatient Health Plans (PIHPs) Prepaid Ambulatory Health Plans (PAHPs)
29 NEW TERMINOLOGY Adverse benefit determination means, for an MCO, PIHP, or PAHP: The denial or limited authorization of a requested service. The reduction, suspension, or termination of a previously authorized service. The denial, in whole or in part, of payment for a service. The failure to provide services in a timely manner, as defined by the State. The failure of an MCO, PIHP, or PAHP to act within the timeframes provided. For residents in rural areas with only one MCO, the denial of his or her right to obtain services outside of the network. The denial of an enrollee's request to dispute a financial liability, including cost sharing, copayments, premiums, deductibles, coinsurance, and other enrollee financial liabilities. 42 CFR (b)-(1) through (7)
30 NEW TERMINOLOGY CONTINUED Appeal means a review by an MCO, PIHP, or PAHP of an adverse benefit determination. Grievance means an expression of dissatisfaction about any matter other than an adverse benefit determination. Grievances may include, but are not limited to, the quality of care and aspects of interpersonal relationships. Grievance also includes an enrollee s right to dispute an extension of time proposed by the MCO, PIHP or PAHP to make an authorization decision. State fair hearing means a due process evidentiary hearing after the enrollee s appeal of the MCO adverse benefit determination has been exhausted. 42 CFR (b)
31 MCO NOTICE TIMELINE REDUCTIONS An MCO, PIHP, PAHP must give timely and adequate notice of adverse benefit determination (ABD) in writing. The notice must give right to request an internal MCO within 60 days of ABD, and if ABD is upheld, a right to request State Fair Hearing within 120 days of notice that ABD was upheld. Timeline for MCO to make ABD Current CFR = 45 days 2017 CFR reduced to 30 days Expedited ABD Current CFR = 3 Working days 2017 CFR reduced to 72 hours 42 CFR (b)
32 APPEALABLE ACTIONS NOW INCLUDE QUESTIONS OF FINANCIAL LIABILITY Hearable issues now include disputes regarding financial liability including questions concerning: Cost sharing Copayments Premiums Deductibles Coinsurance Other enrollee s financial liabilities 42 CFR (b)(7)
33 INTERNAL APPEALS MUST BE EXHAUSTED Beneficiaries will have at least one level of internal appeal with Managed Care Organizations (MCO s), which must be exhausted prior to requesting a Medicaid Fair Hearing. Exception: MCO fails to follow notice and time requirements; = exhausted and launches right to SFH. 42 CFR (c)(3); 402
34 REQUEST FOR STATE FAIR HEARING (SFH) TIME INCREASED TO 120 DAYS By July 1, 2017, Beneficiaries will have 120 days from the date of MCO notice of resolution to file Request for State Fair Hearing. Currently the time period is 90 days. State fair hearing: The enrollee must request a State fair hearing no later than 120 calendar days from the date of the MCO s, PIHP s, or PAHP s notice of resolution (f)(2)
35 CHANGES NEEDED PRIOR TO 7/1/2017 MCO notice of resolution language regarding filing request for State Fair Hearing needs to be changed from the current 90 days to 120 days. MAHS must change its intake process to accept a MCO beneficiary request for State Fair Hearing up to 120 days; currently denies after 90 days.
36 WHAT THE CHANGES MEAN TO YOU CMS continues to provide guidance to states on implementation of the new managed care regulations. The DHHS and MAHS worked together to plan for the managed care regulation changes. The MDHHS included in MCO contracts or sent to MCO Contract Managers the new managed care Notices of Adverse Benefit Determination and Notice of Resolution. l MCOs need to ensure the new notices of internal review are issued with return address to the MCO instead of notices of action referring to avright to hearing and addressed envelope to MAHS.
37 XI. QUESTIONS 37
Docket No CMH Decision and Order
3. Following the most recent assessment of Appellant s status in the program, the CMH determined that Appellant would age out of the autism ABA benefit but would be eligible for ongoing DD services. Testimony
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