NY STATE OF HEATH ASSISTOR CERTIFICATION TRAINING MODULE

NY STATE OF HEATH ASSISTOR CERTIFICATION TRAINING MODULE 8: COMPLAINTS AND APPEALS nystateofhealth. ny. gov 1

LEARNING OBJECTIVES By the end of this lesson, you will be able to: • Define the difference between a complaint and an appeal. • Understand the process a consumer will follow to file a Complaint or an Appeal. • Understand the tracking and reporting methods to send information about appeals and complaints to the Department of Health. nystateofhealth. ny. gov 2

COMPLAINT VERSUS APPEAL According to the dictionary: • Complaint - expression of grief, pain, or dissatisfaction • Appeal - a legal proceeding by which a case is brought before a higher court for review of the decision of a lower court nystateofhealth. ny. gov 3

COMPLAINT VERSUS APPEAL According to Affordable Care Act: Complaint – When an individual participating in the NY State of Health feels the service they received was unsatisfactory. Appeal - When the individual participating in the NY State of Health, does not agree with an eligibility determination, policy or other activity related to their health insurance coverage. nystateofhealth. ny. gov 4

ASSISTOR COMPLAINTS PROCESS 1. Use your customer service skills to defuse the consumer’s emotions and address the issue(s). 2. If the consumer is still dissatisfied, refer them to the Service Center to have their complaint taken over the phone. nystateofhealth. ny. gov 5

COMPLAINT PROCESS 1. Consumer contacts the Service Center. 2. Customer Service Center actively listens to the issue using their service skills to attempt to help the caller (the call will be referred to a supervisor if necessary). 3. Customer Service Center notes the complaint in the call tracking system and submits to a supervisor for review. 4. If the Service Center receives a complaint about an individual Assistor, that Assistor’s manager will follow up on the complaint with the Assistor’s agency. This will ensure that any specific issues underlying the complaint are resolved and that such issues can be corrected moving forward. nystateofhealth. ny. gov 6

APPEAL PROCESS - INDIVIDUAL A consumer can file an appeal based on: • Eligibility determination (e. g. , found eligible for QHP with an APTC and CSR reduction; attestation supports Medicaid eligibility). • Level of APTC and CSR benefit. • Failure of the NY State of Health to provide timely notice of eligibility determination. • Denial of special enrollment periods. • Denial of Medicaid Premium Assistance Payments. • Level of CHPlus Premium. • Eligibility or the level of the Essential Plan. nystateofhealth. ny. gov 7

COVERAGE APPEALS Appeals about Enrollee Health Plan Coverage: Use Existing Processes QHP or Essential Plan or Child Health Plus Enrollee Coverage In some cases, you may make an external appeal with the Department of Financial Services. Medicaid Enrollee Health Plan Coverage Request appeal through the Office of Administrative Hearings. These hearings are in person at LDSS or HRA. nystateofhealth. ny. gov 8

APPEALS PROCESS Refer the consumer to the correct path to file the appeal: • Phone • Fax • Mail nystateofhealth. ny. gov 9

APPEALS PROCESS - INDIVIDUAL Formal Appeal Opened Informal Dispute Resolution Held Hearing Scheduled Hearing Held Eligibility Determination updated in the NY State of Health Marketplace nystateofhealth. ny. gov 10

COMPLAINT VERSUS APPEAL ACTIVITY Please review the scenario and determine: • If it is a complaint, an appeal or neither • If the Assistor did anything incorrectly • What could you do to support them nystateofhealth. ny. gov 11

APPEALS PROCESS – SMALL BUSINESS MARKETPLACE SBM employers and employees applying for health coverage in the NY State of Health have the right to appeal their eligibility determination. SBM employers and employees have 90 days from the date on their eligibility determination notice to request an appeal. Potential enrollees in the Small Business Marketplace may appeal the following: • Finding that an employer is not qualified. • Finding that a potential enrollee is not a qualified employee. • Denial of special enrollment period. nystateofhealth. ny. gov 12

APPEALS PROCESS – SMALL BUSINESS MARKETPLACE Formal Appeal Opened Informal Dispute Resolution Held Desk Review or Hearing Scheduled Desk Review or Hearing Held Eligibility Determination updated in the Small Business Marketplace nystateofhealth. ny. gov 13

HELPING CONSUMERS WITH APPEAL PROCESS It is important for Assistors to understand their role in helping with appeals. Assistors may: • Help the consumer identify and meet the deadline for filing an appeal • Help the consumer understand their appeal rights • Help consumers understand the steps in place to file an appeal and the overall process • Help the consumer locate and access relevant exchange resources (forms, contact information and exchange guidance on appeals) • Provide information about free or low cost legal help • Assist in collecting supporting documentation (screenshots of relevant information from the application) nystateofhealth. ny. gov 14

HELPING CONSUMERS WITH APPEAL PROCESS - CONTINUED It is important for Assistors to understand their role in helping with appeals. Assistors cannot: • Provide legal advice • Recommend specific action with respect to appeal rights • Sign an appeal request • Represent a consumer in an appeal nystateofhealth. ny. gov 15

CULTURAL AND LINGUISTIC COMPETENCY • Complaints and eligibility questions can stem from differences in the way information is expressed and interpreted. • It is imperative that when scheduling appointments, Assistors ask the individual if there are special needs to consider. This will ensure that you are able to: - Actively work to overcome cultural barriers. - Provide additional linguistic options (translation services or access to an ASL interpreter). - Ensure site accessibility. - Block off adequate time to work with complex consumers to help them understand their options. • All of these items will help to ensure that you are providing the best service and outcome to the consumer. nystateofhealth. ny. gov 16

CHECK FOR UNDERSTANDING 1. When an individual participating in the NY State of Health does not agree with an eligibility determination and wants to take action, the term for this action would be a/an: a. b. c. d. Complaint Grievance Appeal Claim nystateofhealth. ny. gov 17

CHECK FOR UNDERSTANDING 2. When an individual participating in the NY State of Health feels the service they received was unsatisfactory, and they wish to report this experience. This is an example of a/an: a. b. c. d. Appeal Grievance Claim Complaint nystateofhealth. ny. gov 18

CHECK FOR UNDERSTANDING 3. What are other examples of reportable complaints (Check all that apply) o Consumer may be upset with the way their personal information is being handled. o Location of the enrollment site. o The color of the paint in the site. o Punctuality of a call back to consumer nystateofhealth. ny. gov 19

CHECK FOR UNDERSTANDING True or False? 4. True or False? As an Assistor you can help the consumer identify and meet the deadline for filing an appeal as well as help the consumer understand the steps in place to file an appeal and the overall process. True nystateofhealth. ny. gov 20

CHECK FOR UNDERSTANDING 5. What entity determines eligibility? a. The Assistor b. The NY State of Health c. Qualified Health Plans d. Local Department of Social Services nystateofhealth. ny. gov 21

CHECK FOR UNDERSTANDING 6. How can a consumer go about filing an Appeal? Check all that apply) o o o Phone Fax Email In Person Mail Online nystateofhealth. ny. gov 22

CHECK FOR UNDERSTANDING True or False? 7. All NY State of Health consumers have 60 days to file a complaint and an appeal. False nystateofhealth. ny. gov 23

CHECK FOR UNDERSTANDING 8. If the Assistor, or Assistor’s Organization cannot defuse the consumer’s emotions, and they want to file a complaint where do you direct them? a. b. c. d. Department of Health Department of Financial Services The Service Center The Governor’s office nystateofhealth. ny. gov 24

WHAT QUESTIONS DO YOU HAVE? nystateofhealth. ny. gov 25