(a) (1) Except as provided in paragraph (2), the State Department of Social Services, acting as the appeals entity, shall allow an applicant or enrollee to request an appeal within 90 days of the date of the notice of an eligibility or enrollment determination, or exemption determination within the Exchange’s jurisdiction, unless there is good cause as provided in Section 10951 of the Welfare and Institutions Code.
(2) The appeals entity shall establish and maintain a process for an applicant or enrollee to request an expedited appeals process where there is immediate need for health services because a standard appeal could seriously jeopardize the appellant’s life, health, or the ability to attain, maintain, or regain maximum function. If an expedited appeal is granted, the decision shall be issued as expeditiously as possible, but no later than five working days after the hearing, unless the appellant agrees to a delay to submit additional documents for the appeals record. If an expedited appeal is denied, the appeals entity shall notify the appellant within three days by telephone or through other commonly available secure electronic means, to be followed by a notice in writing, within five working days of the denial of an expedited appeal. If an expedited appeal is denied, the appeal shall be handled through the standard appeal process.
(b) Appeal requests may be submitted to the appeals entity by telephone, by mail, in person, through the Internet, through other commonly available electronic means, or by facsimile.
(c) The staff of the Exchange, the county, or the State Department of Health Care Services or its designee shall assist the applicant or enrollee in making the appeal request.
(d) (1) Upon receipt of an appeal, the appeals entity shall send timely acknowledgment to the appellant that the appeal has been received. The acknowledgment shall include information relating to the appellant’s eligibility for benefits while the appeal is pending, an explanation that advance payments of the premium tax credit while the appeal is pending may be subject to reconciliation if the appeal is unsuccessful, an explanation that the appellant may participate in informal resolution pursuant to subdivision (g), information regarding how to initiate informal resolution, and an explanation that the appellant shall have the opportunity to review his or her entire eligibility file, including information on how an income determination was made and all papers, requests, documents, and relevant information in the possession of the entity that made the decision that is the subject of the appeal at any time from the date on which an appeal request is filed to the date on which the appeal decision is issued.
(2) Upon receipt of an appeal request, the appeals entity shall send, via secure electronic means, timely notice of the appeal to the Exchange and the county, and the State Department of Health Care Services or its designee if applicable.
(3) Upon receipt of the notice of appeal from the appeals entity, the entity that made the determination of eligibility or enrollment being appealed shall transmit, either as a hardcopy or electronically, the appellant’s eligibility and enrollment records for use in the adjudication of the appeal to the appeals entity.
(e) A member of the board, employee of the Exchange, a county, the State Department of Health Care Services or its designee, or the appeals entity shall not limit or interfere with an applicant’s or enrollee’s right to make an appeal or attempt to direct the individual’s decisions regarding the appeal.
(f) An applicant or enrollee may be represented by counsel or designate an authorized representative to act on his or her behalf, including, but not limited to, when making an appeal request and participating in the informal resolution process provided in subdivision (g).
(g) An applicant or enrollee who files an appeal shall have the opportunity for informal resolution, prior to a hearing, that conforms with all of the following:
(1) A representative of the entity that made the eligibility or enrollment determination shall contact the appellant or the appellant’s appropriately authorized representative and offer to discuss the determination with the appellant if he or she agrees.
(2) The appellant’s right to a hearing shall be preserved if the appellant is dissatisfied with the outcome of the informal resolution process. The appellant or the authorized representative may withdraw the hearing request voluntarily or may agree to a conditional withdrawal that shall list the agreed-upon conditions that the appellant and the Exchange, county, or the State Department of Health Care Services or its designee shall meet.
(3) If the appeal advances to a hearing, the appellant shall not be required to provide duplicative information or documentation that he or she previously provided during the application, redetermination, enrollment, or informal resolution processes.
(4) The informal resolution process shall not delay the timeline for a provision of a hearing.
(5) The informal resolution process is voluntary and neither an appellant’s participation nor nonparticipation in the informal resolution process shall affect the right to a hearing under this section.
(6) For eligibility or enrollment determinations for insurance affordability programs based on modified adjusted gross income (MAGI), the appellant or the appellant’s appropriately authorized representative may initiate the informal resolution process with the entity that made the determination, except that all of the following shall apply:
(A) The Exchange shall conduct informal resolution involving issues related only to the Exchange, including, but not limited to, exemption from the individual responsibility penalty pursuant to Section 1311(d)(4)(H) of the federal act, offers of affordable employer coverage, special enrollment periods, and eligibility for affordable plan options.
(B) Counties shall conduct informal resolution involving issues related to non-MAGI Medi-Cal eligibility or enrollment decisions.
(C) The State Department of Health Care Services or its designee shall conduct informal resolution involving issues related to eligibility or enrollment determinations for programs when the State Department of Health Care Services is the entity making the determination.
(7) The staff involved in the informal resolution process shall try to resolve the issue through a review of case documents, in person or through electronic means as desired by the appellant, and shall give the appellant the opportunity to review case documents, verify the accuracy of submitted documents, and submit updated information or provide further explanation of previously submitted documents.
(8) The informal resolution process set forth by the State Department of Social Services for Medi-Cal fair hearings shall be used for the informal resolutions pursuant to this subdivision and shall require the Exchange, county representative, or the State Department of Health Care Services or its designee to do the following:
(A) Review the file to determine the appropriateness of the action and whether a hearing is needed.
(B) Attempt to resolve the matter if the action was incorrect.
(C) Determine whether a dual agency appeal is required to resolve the matter at hearing and notice the other agency if not already included.
(D) Determine whether interpretation services are necessary and arrange for those services accordingly.
(E) Inform appellants of other agencies that may also be available to resolve the controversy.
(h) (1) A position statement, as required by Section 10952.5 of the Welfare and Institutions Code, shall be made available at least two working days before the hearing on the appeal. The position statement shall be made available electronically by the entity that determined eligibility if the entity has the capacity to send information electronically in a secure manner.
(2) The appeals entity shall send written notice, electronically or in hard copy, to the appellant of the date, time, and location of the hearing no later than 15 days prior to the date of the hearing. If the date, time, and location of the hearing are prohibitive of participation by the appellant, the appeals entity shall make reasonable efforts to set a reasonable, mutually convenient date, time, and location. The notice shall explain what format the hearing shall be held in, via telephone or video conference or in person, and include the right of the appellant to request that the hearing be held via telephone or video conference or in person. The notice shall include instructions for submitting the request on the notice, by telephone or through other commonly available electronic means.
(3) The hearing format may be held via telephone or video conference, unless the appellant requests the hearing be held in person pursuant to paragraph (2).
(4) The hearing shall be an evidentiary hearing where the appellant may present evidence, bring witnesses, establish all relevant facts and circumstances, and question or refute any testimony or evidence, including, but not limited to, the opportunity to confront and cross-examine adverse witnesses, if any.
(5) The hearing shall be conducted by one or more impartial officials who have not been directly involved in the eligibility or enrollment determination or any prior appeal decision in the same matter.
(6) The appellant shall have the opportunity to review his or her appeal record, case file, and all documents to be used by the appeals entity at the hearing, at a reasonable time before the date of the hearing as well as during the hearing.
(7) Cases and evidence shall be reviewed de novo by the appeals entity.
(i) Decisions shall be made within 90 days from the date the appeal is filed and shall be based exclusively on the application of the applicable laws and eligibility and enrollment rules to the information used to make the eligibility or enrollment decision, as well as any other information provided by the appellant during the course of the appeal. The content of the decision of appeal shall include a decision with a plain language description of the effect of the decision on the appellant’s eligibility or enrollment, a summary of the facts relevant to the appeal, an identification of the legal basis for the decision, and the effective date of the decision, which may be retroactive at the election of the appellant if the appellant is otherwise eligible.
(j) Upon adjudication of the appeal, the appeals entity shall transmit the decision of appeal to the entity that made the eligibility or enrollment determination via a secure electronic means.
(k) If an appellant disagrees with the decision of the appeals entity, he or she may make an appeal request regarding coverage in a qualified health plan through the Exchange to the federal Department of Health and Human Services within 30 days of the notice of decision through any of the methods in subdivision (b).
(l) An appellant may also seek judicial review to the extent provided by law. Appeal to the federal Department of Health and Human Services is not a prerequisite for seeking judicial review, nor shall seeking an appeal to the federal Department of Health and Human Services preclude a judicial review.
(m) Nothing in this section, or in Sections 100506.1 and 100506.2, shall limit or reduce an appellant’s rights to notice, hearing, and appeal under Medi-Cal, county indigent programs, or any other public programs.
(n) This section shall be implemented only to the extent it does not conflict with federal law.
(Added by Stats. 2014, Ch. 869, Sec. 5. (AB 617) Effective January 1, 2015.)
Last modified: October 8, 2018