|
|
During the appeal process, a new change may occur before the hearing decision is made that affects the customer’s eligibility, level of services, premium, or share of cost amount.
The table below explains how changes are processed when they are received during the appeal process.
| If... | Then... |
· The customer is approved for continued benefits during the appeal process; AND · The reported change will result in an adverse action. |
The change is not processed until the hearing process ends. |
· The customer is approved for continued benefits during the appeal process; AND · The change results in a non-adverse action |
The change is processed and the customer is sent a new decision letter. |
The customer does not have continued benefits. |
The change is processed and the customer is sent a new decision letter no matter what the eligibility result is. |
Term |
Definition |
Adverse Action |
In general, an adverse action is any action to: · Deny, suspend or stop MA; · Increase the customer’s share of cost or premium amount; or · Reduce services or benefits. NOTE This includes actions to approve emergency services only instead of full MA coverage and changes from full MA coverage to emergency services. |
Notice of Action |
A notice that explains the action that has been taken on a customer’s case. |
Advance notice is given whenever an adverse action is taken before the decision on the original issue.
The customer may ask for a fair hearing on the new adverse action and has 35 days from the new notice to file the request.
This requirement applies to the following programs:
Program |
Legal Authorities |
All Programs |
42 CFR 431.231 AAC R9-34-114 |