most discussion among legal advocates for Medicaid beneficiaries. The concern is rooted in the fact that it is the wording of the regulation that will control, not the preamble or webinar statements. Moreover, the proposed regulation § 438.420 defines but then does not use the term in the remainder of the rule. We are “timely appeal” suggesting small clarifications to address possible confusion about the requirements for continued benefits. We also support the amendments made to clarify requirements for recoupment but are recommending some additional protections for people with disabilities and limited English proficiency. RECOMMENDATION: Definitions. As used in this section— Timely filinges means filing on or before the later of the following— Within 10 calendar days of the MCO, PIHP, or PAHP mailing the notice of adverse benefit determination. Before the date the adverse coverage determination is to take effect. (The MCO, PIHP, PAHP must mail an advance notice as required by § 438.404(c)(1)). (b) Continuation of benefits. The MCO, PIHP, or PAHP must continue the enrollee's benefits if all of the following occur: … (1) The enrollee or the provider timely files files the appeal timely; ….. (d) Enrollee responsibility for services furnished while the appeal is pending. Such practices must be consistently applied within the State under … managed care and FFS delivery systems. To recover costs from an enrollee who has LEP or has a disability that requires information provided in alternate formats, the MCO, PIHP, or PAHP may only recover the cost of the services furnished to the enrollee while the MCO, PIHP or PAHP appeal and State fair hearing are pending if the MCO, PIHP, or PAHP can document that it provided the enrollee with information about recovery in the enrollee's language or in an alternate format to meet the needs of an individual with a disability. New § 431.234 De novo State fair hearing – Under Goldberg, a constitutionally impartial hearing will not occur until the individual reached the state fair hearing level of appeal. See, e.g., Daniels v. Wadley, . To ensure this fairness, the state fair hearing needs to occur de novo. We recommend:
most discussion among legal advocates for Medicaid beneficiaries. The concern is rooted in the fact that it is the wording of the regulation that will control, not the preamble or webinar statements. Moreover, the proposed regulation § 438.420 defines “timely appeal” but then does not use the term in the remainder of the rule. We are suggesting small clarifications to address possible confusion about the requirements for continued benefits. We also support the amendments made to clarify requirements for recoupment but are recommending some additional protections for people with disabilities and limited English proficiency. RECOMMENDATION: Definitions. As used in this section— Timely filinges means filing on or before the later of the following— Within 10 calendar days of the MCO, PIHP, or PAHP mailing the notice of adverse benefit determination. Before the date the adverse coverage determination is to take effect. (The MCO, PIHP, PAHP must mail an advance notice as required by § 438.404(c)(1)). (b) Continuation of benefits. The MCO, PIHP, or PAHP must continue the enrollee's benefits if all of the following occur: … (1) The enrollee or the provider timely files files the appeal timely; ….. (d) Enrollee responsibility for services furnished while the appeal is pending. … Such practices must be consistently applied within the State under managed care and FFS delivery systems. To recover costs from an enrollee who has LEP or has a disability that requires information provided in alternate formats, the MCO, PIHP, or PAHP may only recover the cost of the services furnished to the enrollee while the MCO, PIHP or PAHP appeal and State fair hearing are pending if the MCO, PIHP, or PAHP can document that it provided the enrollee with information about recovery in the enrollee's language or in an alternate format to meet the needs of an individual with a disability. New § 431.234 – De novo State fair hearing Under Goldberg, a constitutionally impartial hearing will not occur until the individual reached the state fair hearing level of appeal. See, e.g., Daniels v. Wadley, . To ensure this fairness, the state fair hearing needs to occur de novo. We recommend:
Guide-to-proposed-Managed-Care-Rule.docx