***This version of the Health Care Programs Manual has been replaced and is no longer in effect. Please see the current Health Care Programs Manual for policy in effect as of December 1, 2006.***

MDHS Health Care Programs Manual (Eligibility Policy through 11/30/06)

Chapter 0917 - Appeals

All chapters are numbered beginning with 09. The first chapter is 0901 (Table of Contents).

Chapter 0917

0917

APPEALS

PDF(s): Jul 98

0917.03

APPEALABLE ISSUES

PDF(s): Jul 98

0917.05

APPEAL RIGHTS

PDF(s): Jul 98

0917.07

APPEAL REQUESTS

PDF(s): Jul 98

0917.09

APPEAL HEARINGS

PDF(s): Jul 98

0917.09.03

APPEAL HEARING REIMBURSEMENT

PDF(s): Jul 98

0917.11

CONTINUATION OF BENEFITS

PDF(s): Dec 02

0917.13

EFFECT OF APPEAL DECISION

PDF(s): Jul 98

APPEALS 0917

When people are dissatisfied with a county or state agency decision, they can appeal for a review of the matter by the DHS Appeals Office. The Appeals Office will determine whether DHS has jurisdiction over the appeal and whether the appeal is timely. See §0917.03 (Appealable Issues) and §0917.07 (Appeal Requests).

Inform people of their right to appeal whenever you take an action that affects their coverage or benefits. MAXIS and MMIS notices include standard language about appeal rights. See §0917.05 (Appeal Rights) and §0916.03 (Content of Notices).

Continue coverage pending the outcome of the appeal unless the client requests otherwise in writing. See §0917.11 (Continuation of Benefits).

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

APPEALABLE ISSUES 0917.03

Applicants, enrollees, former enrollees, and some people who have financial obligations to enrollees may appeal any action by the county or state agency which affects benefits, program participation, or obligations under the programs.

Although there are some issues which are not appealable, forward ALL appeal requests to:

DHS Appeals Office

444 Lafayette Road

St. Paul, Minnesota 55155-3813

The Appeals Office will decide if an issue is appealable and convene a hearing.

Commonly appealed actions for the health care programs include:

• Denial, reduction, cancellation, or termination of assistance. • Spenddown and premium determinations. • Denial of a good cause exemption, such as good cause for non-payment of a MinnesotaCare premium or good cause for non-cooperation with medical support. • The agency's failure to act on an application within the timeliness standards in §0904.07.03 (Date of Application). • Effective dates of coverage.

The Appeals Office may deny or dismiss an appeal request if:

• It is withdrawn in writing. • It is not received within the timeliness standard in §0917.07 (Appeal Requests). • The client, financially responsible person, or representative fails to appear for a hearing and cannot show good cause for doing so. • DHS has no jurisdiction to hear the appeal.

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

APPEAL RIGHTS 0917.05

When an action affects enrollees' coverage or the contribution of someone determined financially responsible for them, provide information, in writing, on:

• The right to appeal to the county agency, MinnesotaCare office, or directly to the State Appeals Office for a fair hearing. • How to file an appeal.

All notices must include this information. See §0916.03 (Content of Notices). MMIS and MAXIS notices include standard language containing the required information. The HCAPP and CAF also include standard language on appeals for applicants and enrollees due for renewal or recertification.

People also receive information from the Appeals Office regarding:

• The right to represent themselves at the hearing or to have another person represent them. • The right to examine documents and records in the case file. Do not release information classified as confidential. See §0903.03.05 (Client Rights - Privacy Rights). • The right to question or refute any testimony or evidence given at the hearing. • The right to submit evidence at the hearing to establish facts and circumstances in the case.

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

APPEAL REQUESTS 0917.07

You must refer all appeal requests to the State Appeals Office. Do this regardless of when you receive the request, and regardless of the person's reason for making a late appeal request. The Appeals Office will convene a hearing and decide the issue of timeliness or good cause at that time. See §0917.11 (Continuation of Benefits).

For written appeals, clients may use the Appeal to State Agency form (DHS 0033) or may send a letter indicating disagreement with the county or state agency's decision.

People must request an appeal hearing in writing and state what action they are appealing. They must request the appeal hearing within 30 days of receiving a notice of proposed action, or show good cause for not requesting within that time. People may file an appeal up to 90 days after receiving the notice of proposed action if they show good cause for not filing within 30 days.

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

APPEAL HEARINGS 0917.09

Before the hearing, offer the client an opportunity to resolve the appealed issue informally. The client may request an agency conference including a supervisor or the agency director. The conference may be conducted by phone or in person. If you resolve the issue through a conference or other means, ask the client to sign a written request to withdraw the appeal. Do not delay sending the appeal request to the Appeals Office pending an informal conference.

To allow for proper notification, hearings normally are held at least 5 days after the appeal notice is filed with the Appeals Office. Hearings can be held sooner if the client and referee consent.

The referee may conduct a face-to-face hearing, or by telephone if the client agrees. County agencies must have equipment necessary to conduct hearings by telephone (such as a telephone speaker attachment) available.

Complete a summary of the issues (including timeliness issues) and county or state agency actions leading to the appeal on the State Agency Appeal Summary form (DHS 0035) or a memo including all pertinent information. Provide copies to the client and the appeals office. The client may give additional evidence at the hearing. Evidence given at the hearing is the basis for the referee's recommendation and the commissioner's decision.

The referee recommends an order to the commissioner's representative, who then issues an order affirming, reversing, or modifying the action of the county or state agency. If the commissioner's representative disagrees with the referee's recommendation, each party then has 10 days to present additional written arguments on the matter. The commissioner's representative then issues a decision.

The client or the county or state agency may request reconsideration by the commissioner's representative within 30 days after the date the commissioner's representative issues the order. A request for reconsideration should state the reasons the dissatisfied party believes the original order is incorrect. The commissioner's representative may reconsider an order upon request of either party or on the commissioner's representative's own motion and will then issue an amended order or an order affirming the original order. The original order takes effect even if there is a request for reconsideration.

The client or the county or state agency may also appeal to district court within 30 days after the date the commissioner's representative issued an order, an amended order, or an order affirming the original order. Either party may also appeal to district court to enforce an appeal decision.

Although the commissioner's representative can order that the client receive benefits during the entire time of appeal, in most cases the Department order takes effect while the appeal to district court is pending. Do not continue coverage during an appeal to district court unless the final Department order specifically directs you to do so.

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

APPEAL HEARING REIMBURSEMENT 0917.09.03

Reimburse clients for reasonable and necessary expenses they incur to attend an in-person hearing or a telephone hearing scheduled at a location other than the client's home, such as the county agency. Examples are:

• Transportation costs to and from the hearing for clients, their authorized representatives, and any witnesses. Use the current IRS rate. See §0911.09.03.09 (Self-Employment Transportation). • Child care costs. • Payment for a medical assessment. • Cost of interpreter services.

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

CONTINUATION OF BENEFITS 0917.11

Unless an enrollee requests otherwise in writing, continue coverage if the request for an appeal is received before the effective date of the action or within 10 days after the date the notice is mailed, whichever if later. If the end of a notice period falls on a weekend or holiday, consider an appeal the unit makes on the next working day to be timely for the purpose of continued benefits.

See the MinnesotaCare section for information on continued coverage when the appeal is based on cancellation for non-payment.

Notify people that they will be required to repay benefits continued while the appeal is pending if they lose their appeal. Also notify people that they must continue to pay premiums or meet a spenddown if applicable.

If a change not related to the issue under appeal occurs while benefits are continuing, notify the enrollee of any adverse action. Take the action unless it is also appealed.

EXAMPLE:

A MinnesotaCare enrollee appeals the removal of a household member from coverage based on availability of other insurance. At the enrollee's request, coverage is continued for the entire household, including the member with other insurance, while the appeal is pending. The household must continue to pay the premium for the entire household.

While the appeal is pending, a new member with income moves into the household resulting in an increased premium. Increase the premium unless the household files a separate appeal of that action.

EXAMPLE:

An MA household appeals an increased spenddown due to increased income. At the household's request, coverage is continued at the old spenddown amount while the appeal is pending. Before the appeal is heard, the household fails to submit a scheduled recertification. Send a notice of termination for failure to comply with recertification requirements. Terminate MA unless the household submits a complete recertification before the effective date of termination OR appeals the termination.

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MinnesotaCare:

Inform enrollees who wish to continue benefits while an appeal is pending that they must continue to pay premiums. For adverse actions other than cancellation for non-payment, all premiums that are due must be paid before the effective date of the proposed action or within 10 days after the date the notice is mailed, whichever is later, for benefits to continue. For cancellation for non-payment, coverage will be reinstated if all due premiums are paid within 20 days after the effective date of cancellation.

EXAMPLE:

MinnesotaCare sends Rob a cancellation notice on December 15 due to the availability of other insurance. Rob wishes to appeal the cancellation. In order to continue benefits pending the appeal, he must pay the January premium by the last working day in December.

EXAMPLE:

MinnesotaCare sends Mary a cancellation notice for non-payment of her December premium on November 15. If Mary sends the premium by the last working day of November, her coverage will be continued. If she does not send the premium, her coverage will be canceled effective December 1. If she appeals the cancellation and wishes to continue benefits, she must pay the December and January premiums by December 10.

If the appeal involves a dispute about the amount of the premium, require the enrollee to pay the premium that was in effect before the action being appealed while the appeal is pending.

EXAMPLE:

Based on income information submitted with the annual renewal, MinnesotaCare determines that the McDonald family's premium will increase from $49 to $82 per month effective February 1. Mr. McDonald appeals the increased premium. Continue coverage at $49 per month while the appeal is pending. If the appeal decision upholds the increased premium beginning February 1, the McDonalds will have to pay the $33 per month difference for all months when the appeal was pending for coverage to continue.

If the enrollee loses an appeal of cancellation for non-payment of premium and coverage was continued during the appeal, begin the 4-month penalty period with the 1st available month after you receive the appeal decision. See §0915.11 (Fail to Pay Premium/Voluntary Cancellation).

EXAMPLE:

Sally appealed her March 1 cancellation for non-payment and requested coverage while the appeal was pending. She paid the March premium by March 10 and also paid all premiums due while the appeal was pending. On April 24, MinnesotaCare receives an appeal decision upholding the cancellation. Sally has paid the May premium and the cap payment for May has gone out. Begin the 4-month penalty period in June. If the appeal decision had been received on April 15, the penalty period would begin in May.

MA/GAMC:

Follow general provisions.

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***This version of the manual is no longer in effect as of December 1, 2006.*** Current Manual.

EFFECT OF APPEAL DECISION 0917.13

When the appeals office reverses the agency decision, follow the directive in the appeal decision. Required actions may include:

• Reconsidering a previous denial or cancellation based on new information. The appeal decision will specify what additional information, if any, the client must provide for the decision to be reconsidered. • Approving coverage for a previously denied application. • Reinstating coverage for a previously canceled household. • Reversing a good cause finding.

When a client who continues to receive coverage during the appeal process loses an appeal, implement the appealed action beginning the 1st possible month. No additional notice is required. See §0917.11 (Continuation of Benefits).

MinnesotaCare:

Follow general provisions.

MA/GAMC:

The Appeals Office attaches the Compliance With State Decision form (DHS 666) to the appeal decision. Complete and return the form to them.

M. S. 256.045

M. S. 256.9361

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