Anticipate spike in “fair hearings” that address eligibility decisions as states ramp Medicaid Unwinding efforts
With 12 months to initiate and 14 months to complete renewal for all individuals enrolled in Medicaid, states should also prepare for the significant increase in individuals who will appeal eligibility decisions through Medicaid’s “fair hearings” process. As of October 2022, over 90 million individuals were enrolled in Medicaid and CHIP.
States must provide an opportunity for a fair hearing to any applicant whose request for medical assistance through Medicaid is denied or not acted upon in a reasonable time. This includes eligibility determinations where the individual believes the agency determining eligibility has made an error.[i] Generally, states must take final administrative action on a fair hearing request within 90 days of an individual requesting an appeal and “as expeditiously as possible” on expedited fair hearing requests.[ii]
In April 2022, the Centers for Medicare & Medicaid Services (CMS) provided Medicaid agencies with helpful guidance for assessing the state’s capacity to prepare for an increased volume of fair hearing requests when the continuous Medicaid eligibility ends on March 31, 2023. The guidance also included strategies the agencies can use to address the expected increase in volume.[iii]
Among these strategies, CMS describes how states can leverage contractors' services to assist with processing appeals. These tasks include:
- Intaking the fair hearing request
- Contacting consumers who request a fair hearing to collect missing information
- Scheduling the fair hearing
- Collecting and managing evidence for the fair hearing
- Sending fair hearing notices
- Performing other administrative tasks to support the fair hearing process
By leveraging contractor services, government agencies can respond to surges in fair hearing requests by focusing their internal resources on those appeal-related tasks that the agency must perform, including conducting the fair hearing; evaluating evidence; developing, writing, and issuing fair hearing decisions; reviewing requests for expedited hearings; and any other function that requires discretion.
Support for State Fair Hearing Process
Maximus has a deep understanding of the Medicaid fair hearing process. We assist many Medicaid programs and federal and state-based exchanges, which must also provide individuals with the right to appeal eligibility decisions. In addition to our vast experience, our success is founded on:
- Trained staff that understand the sensitive nature of appeals and the frustration and concern individuals may have when they receive notice that they are not eligible, or are no longer eligible, for coverage
- Efficient systems that capture a complete record of the appeal automate workflow, and reduce the administrative burden on agencies
- Experience assisting people with disabilities and individuals with limited English proficiencies to ensure equitable access to fair hearings
Maximus also has a proven track record in administering the Informal Dispute Resolution (IDR) process for Medicaid programs and federal and state-based exchanges throughout the nation. Informal dispute resolution was identified in CMS guidance as an effective strategy in which contractors can assist agencies in managing the expected increase in appeals.
Specially trained Maximus staff conduct IDR conferences to educate consumers about the eligibility decision, respond to questions, and seek resolution before the hearing. The Maximus IDR process quickly resolves disputes, which increases consumer satisfaction and avoids costly hearings, allowing state resources to be preserved for those requesting a fair hearing. The Maximus IDR process reduced the number of fair hearing requests by over 80 percent for one large-scale government program.
To learn more about how Maximus can help your agency handle appeals and implement an informal dispute resolution process, visit maximus.com/phe-unwinding or contact us at USServices@maximus.com.
[i] This blog focuses on appeals of Medicaid eligibility and does not cover an individual’s right to appeal an eligibility decision for coverage of a specific service
[ii]Strategic Approaches to Support State Fair Hearings as States Resume Normal Eligibility and Enrollment Operations After the COVID-19 PHE (medicaid.gov)