IT and Implementation CommitteeManaging Appeals and Notifications

June 13, 2012

2

Agenda − Welcome & Overview − Framing the Essential Question 15 min

Goals and objectives Definitions Questions for IT and Implementation Committee and Board What appeals are in scope for COHBE? What notifications are in scope for COHBE?

− Appeals Discussion 20 min

Appeal scenarios

Roles in appeal process

Overview of current HCPF appeal process Appeals process business requirements

Open Questions on Appeals

− Notifications Discussion 20 min Notifications Scenarios Notices business requirements Open Questions on Notifications

− Next steps 5 min

3

Goals and Objectives

Goals and Objectives:− Support SB 11 200 intent to increase access, affordability and choice for ‐

individuals and small employers purchasing health insurance in Colorado.

− Facilitate a smooth and efficient appeals process for individuals and employers – including handoffs between organizations

− Meet the Exchange implementation timeline

4

Definitions

− For the purposes of this discussion, the following definition of appeals is being used:

an application or proceeding for review by a higher authority, or a formal question as to the correctness of a ruling or decision

− Notices will be the method by which COHBE draws attention to, makes known or announces a decision or change that has impact to the individual or employer by email or in writing

5

Questions for the Committee for today:− What appeals should the Exchange handle and which should

be referred to other entities? − What Notices should be generated by the Exchange? (many of

these are identified by current regulations)− What are the basic business requirements for the Appeals and

Notices processes?

6

Scope of Discussion: AppealsTypes of Appeals

Category Specific Appeal In Scope for COHBE?

Individual Mandate Exemption Denial of Exemption No – Appeal to be passed to Federal Call Center (at least in initial years)

Individual Eligibility for public assistance

Medicaid or CHP eligibility / information / transfer

No

Individual Eligibility for subsidies APTC or CSR amount Yes

Individual APTC / CSR not applied correctly

APTC or CSR not applied correctly to premium

Yes

SHOP – Employer appeals employee eligibility for APTC / CSR (EEI-19.51)

Employer wants to appeal determination of employees eligibility for APTC /CSR

Yes

SHOP Eligibility Small business eligibility for PTC Yes

SHOP Eligibility Small business PTC amount Yes

SHOP Premium Billing Amount of bill, payments received, past due amounts, etc

Yes

The focus of today’s discussion on Appeals

Other types of disputes (e.g., individual billing disputes, coverage issues) are NOT in scope for the Exchange. These will be handled by carriers, the DOI or other agencies.

7

Individual Eligibility Appeals

Enter eligibility Information

Determine Eligibility for APTC / CSR

Denial of eligibility for

subsidies shared with

customer

Eligible?

Yes

No

Yes

Inform customer of

eligibility and transfer to

PEAK

Shop for QHPs

Inform customer of eligibility

determination for subsidies

Cust

omer

Exch

ange

Apply for Exemption

No

Yes

Determine eligibility for

Medicaid / CHP

Eligible?

Inform customer of

eligibility determination

Determine Eligibility for

Individual Mandate

Exemption

Fede

ral A

genc

y

Appeal?

Guiding Principle: The appeal process will be handled by the agency which owns the determination that the customer desires. For example, if a customer wants Medicaid but was denied it, HCPF will manage the appeals process; however, if the customer wants an APTC or feels that a tax credit was incorrect, COHBE will handle the appeal.

Appeal?

There is also the opportunity to appeal if APTC / CSR is not applied correctly to the premium

Appeal?

There is also the opportunity to appeal if the data was not transferred to PEAK correctly

No

MAG

I

Eligible?

8

SHOP Eligibility Appeals Opportunities

Enter eligibility Information

Yes

No

Inform Employer of

eligibility determinationEm

ploy

erEx

chan

ge

Apply for Premium Tax

Credit

Determine eligibility for Premium Tax

Credit

Appeal?

Eligible?

Determine amount of

Premium Tax Credit

9

Role in appeals process

Individual/Employee Initiates eligibility appeals process if not satisfied with Exchange eligibility determination.

Employer Initiates eligibility appeals process if not satisfied with Exchange eligibility determination to purchase on SHOP or for PTC .

Exchange • Determines individual eligibility for subsidies. • Notifies individuals of the results of eligibility determinations and provides

information on eligibility appeal rights • Accepts and adjudicates individual appeals regarding eligibility determinations

Process, staffing and timing for resolving appeals is TBD.

DOI Use existing processes to resolve problems, answer questions, file complaints. Complaints will include: denial of coverage, claims issues, etc.

Carrier Use existing internal and external appeals process to handle questions and disputes related to billing, covered benefits, etc.

Navigator May initiate eligibility appeals process if not satisfied with Exchange eligibility determination on behalf of individual

HCPF Use existing internal and external appeals processes for determining whether individual is eligible for public assistance programs.

Federal agency Manage appeals process for individual mandate exemptions.

10

Appeals Process Business RequirementsThe Appeals process should:− Include a mechanism for tracking the life cycle of appeals and outcomes− Include the ability to attach documents and other digital material to an appeal− Segregate appeals processes from other activities to ensure proper oversight and approval

levels for appeals activities− Ensure proper notification of all participants in appeals process with enough time to

gather data and review appeals materials − Be able to handle inter-agency disputes − Ensure customer has access to coverage until appeal process is finished (?)− Provide for both an informal appeals resolution process and a formal appeals process.

Include the ability to escalate to a neutral third party.− Follow all applicable laws− Maximize the use of technology such that appeals can be addressed without the Client

having to participate in a face-to-face meeting with a COHBE representative− Use additional data sources as deemed appropriate (by COHBE)− Use self-attestation as appropriate (need to define these conditions)

11

For Comparison - Current HCPF Appeals Process

For Medicaid and CHP Eligibility Appeals:− Client sent notification within ten days of decision regarding eligibility,

enrollment and cost sharing− An applicant who disagrees with a denial regarding eligibility, enrollment or

cost sharing has 30 days from notification date to appeal decision in writing to the Office of Administrative Courts

− Department will coordinate appeals process with county or Medical Assistance site. County or Medical assistance site will review data entry and application for errors and then notify applicant and Department in writing once review is complete.

− Client can request dispute resolution conference or formal hearing with Grievance Committee over the phone or in person

− If eligible person is enrolled in CHP+ or Medicaid, the person can remain enrolled pending the decision of the appeal

12

Other Thoughts for Discussion on Appeals− Does COHBE want to develop an appeals process that is similar to the HCPF

process in existence today? This can ensure individuals follow a consistent process and can minimize confusion. Any drawbacks to adopting current HCPF process? (note – we assume the COHBE contact center will handle the first line of questions/appeals rather than County or Medical offices for appeals that fall into the scope of COHBE).

− Is COHBE maximizing efficiencies by building on existing infrastructure to manage appeals?

− What information needs to be shared between COHBE and its key stakeholders to ensure individuals and employers are given fair and timely appeals?

13

Scope of Discussion: NoticesTypes of Notices

Category Specific Notice In Scope for COHBE?

Individual Exchange - Change in Medicaid / CHP eligibility

No longer eligible – go to the Exchange to check for eligibility for subsidies (APTC / CSR)

To be discussed – We believe notice will be generated by CBMS telling person about COHBE opportunity

SHOP – Employee no longer eligible

Employer dropped your coverage – go to the individual exchange to apply for coverage

Yes

SHOP and Individual - QHP no longer offered

QHP has been decertified or pulled by carrier, go to the Exchange and select another plan

Yes

SHOP and Individual - Open enrollment notification

Open enrollment period will start soon Yes

SHOP – Bill past due Small business payment delinquency notice Yes

Individual – Bill past due Exchange received notification from Carrier that individual is not paying bills

No

SHOP – employer no longer eligible for PTC

Employer is no longer eligible for PTC due to change in circumstance

Yes

SHOP – notice to employer that an employee was determined eligible for APTC / CSR

One of your employees was determined to be eligible for APTC / CSP

Yes

SHOP – employer has filed appeal for employees APTC

Notice to employee that their employer has filed an appeal disputing the employee’s eligibility for APTC / CSR

Yes

The focus for today’s discussion on Notices

14

NoticesNotices are Sent to Individuals:− Before open enrollment− When the Exchange receives information that the individual is no longer

eligible for subsidies on the Exchange due to age, change in MAGI determination or other life event

− When an employee is no longer covered under an employer’s plan− When a QHP is no longer available − If their employer appeals their APTC / CSR eligibility

Notices are sent to Employers:− When they are delinquent in paying their premium− When a QHP is no longer available− Before open enrollment− When one of their employees is determined to be eligible for APTC / CSR

15

Notices Business Requirements

Notices should:− Be clear, concise and written at the right level and in the right language for

the intended audience− Be accurate− Ensure clear notification of actions to be taken, and provide enough time

for the individual or employer to gather data and take appropriate action − Be ‘legally supportable’ − Be delivered in the most efficient manner, taking into consideration the

customer’s preferences, the need for traceability, and the mission of the Exchange

16

Other Thoughts for Discussion on Notices

− What considerations need to be given during COHBE’s design phase to ensure the technology platform gives accurate and timely notifications?

17

Next Steps