210 R.I. Code R. 210-RICR-10-05-2.2

Current through December 3, 2024

Section 210-RICR-10-05-2.2 - Appeals: General Provisions

2.2.1APPEAL PROCESS

A. The filing of an appeal initiates the hearing process. There are multiple opportunities to resolve an appeal while a hearing is pending.

1. Notification of Appeal Rights. An agency must include on all application forms - paper and electronic - a statement of the applicant's right to appeal and request a hearing related to any agency action related to eligibility; the process for determining eligibility; or a change in the scope, amount, or duration of assistance. Such notices must also state the:

a. Nature of the agency action, the legal basis for the action, the date the action takes effect, the right to representation, the process for review of agency documents if appealing and requesting a hearing, as well as the timelines and locations for doing so; and

b. Except for HSRI notices, information about continuation or reinstatement of assistance while an appeal is pending, as indicated in the aid pending provisions contained in § 2.2.2 of this Part.

2. Notices may contain an appeal request form, indicate the ways to obtain such a form, or provide information on the acceptable format for submitting an appeal if a form is not required or available. Individuals participating in publicly funded health and human services programs with eligibility administered through the state's web-based integrated eligibility system (IES) may have the option of obtaining all formal notices of agency action and other official communications through the user's private, secure online account created through the IES.

3. The state agency must not limit or interfere with an appellant's freedom to make a request for a hearing.

4. Procedures for Filing an Appeal. Appeal Request. An affected party may file an appeal in the format designated for such purposes, or in any other format allowed under applicable laws and regulations. The EHO will accept appeals via the state's web-based IES. An affected party may also download the EHO Appeal Form and file an appeal by traditional means (by postal mail, fax, or personal or commercial delivery). A complete and up-to-date appeal request form is located on the EOHHS website at: www.eohhs.ri.gov

a. An affected party may request assistance in filing an appeal by contacting the agency, the HSRI Contact Center (for enrollees in Medicaid or QHP via the state's web-based IES), or the EHO.

b. The appellant must provide an appeal request that states the reason(s) for the appeal.

5. Appeal Date -The appeal date determines whether aid pending is available and if the appeal was submitted in accordance with applicable timelines. If mailed, the appeal date is the date the form or letter is first received by either the EHO or the agency. If the appeal is filed via telephone or fax, the appeal date is the date the contact is made with the agency or EHO. If the appeal is filed online through the appellant's account with the state's web-based IES, the appeal date is the date the appeal appears in the appellant's account.

6. Agency/Appeal response. The EHO is responsible for ensuring that all appeals are documented properly upon receipt in the electronic appeal database and referred, as applicable, for responses to the appropriate unit of the agency that took the action.

a. Components of the Response - The agency/appeal response is prepared by a representative of the agency and cites the rule, policy, procedure, and/or statute providing the legal justification for the agency action in dispute.

b. Confidentiality - The agency and/or the EHO must take whatever appropriate measures are necessary to ensure any private or confidential information contained in the appeal, and any response prepared, are protected properly to the full extent required by applicable federal and/or state laws, rules or regulations.

c. Agency/Program Specific Provisions - HSRI -- The EHO must inform HSRI as soon as possible of any appeals related to HSRI programs that are filed solely through the EHO. HSRI must be provided with the opportunity to respond to any such appeals and appear at the hearing even in circumstances in which another agency bears principal responsibility for preparing the agency/appeal response. Additional provisions on agency/program specific requirements located in § 2.4 of this Part.

7. Appeal Review. The EHO reviews the appeal to determine if it has been submitted in accordance with the applicable procedures and filing requirements and applicable federal and state laws, regulations, and/or rules.

a. Types of appeals -- For most health and human services programs, an appeal filed properly will result in a scheduled hearing. Exceptions include the circumstances identified in 42 C.F.R. § 431.220(a) related to changes in law or policy affecting an entire class of beneficiaries, or the appellant withdraws the appeal. Circumstances that shall provide an opportunity for a hearing include, but are not limited to:

(1) Affected party's claim for assistance is denied or not acted upon within the required timeframe;

(2) Affected party believes that an agency has acted erroneously in terminating, suspending, or reducing eligibility; or delaying the delivery of and/or terminating, suspending, or reducing the scope, amount, or duration of assistance or the manner in which it is delivered;

(3) Affected party believes that agency's determination related to initial screening, placement, periodic review, or intermittent or regular evaluation of a plan that initiates or affects access to assistance is erroneous or contrary to prevailing standards of practice.

(4) Affected party believes that the agency has limited the freedom to choose among providers without the appropriate federal and/or state authority;

(5) Affected party believes the agency erroneously calculated: the amount of assistance; a payment, or a contribution to the cost of assistance; or the required payment or reimbursement relative to prevailing agency rules, contract obligations, or other binding agreement;

(6) Affected party believes the agency's decision about placement, care planning, or case management, or choice of services is inappropriate, erroneous, or contrary to prevailing standards of practice;

(7) Affected party believes the agency's action with respect to licensure, certification, sanction, or scope of practice was made in error or inappropriately limits or restrains the ability to participate in a program or practice;

(8) Affected party claims discrimination based on age, disability, gender, sexual preference, race, religion, national origin, or color (additional specialized forms may need to be filed);

(9) Affected party believes agency indication of abuse or neglect unjustified or in error;

(10) Affected party believes a nursing facility or assisted living residence decision to transfer or discharge is erroneous;

(11) Affected party wishes to challenge the denial of coverage of, or payment for, health care/services based on an interpretation of medical necessity criteria, prior-authorization rules, managed care rules; and/or

(12) Any program specific matters that the agency has identified publicly by rule or notice that qualifies as an agency action subject to appeal.

(13) Acknowledgement of an appeal - The EHO must send a timely acknowledgment to the appellant upon receipt of the appeal request. The acknowledgement must contain information about the formal and informal options for resolving the appeal including the administrative fair hearing process.

b. Duration - An appeal remains open until:

(1) An affected party voluntarily withdraws it and the withdrawal is confirmed without undue delay by the EHO in writing; or

(2) An affected party or an affected party's representative fails to appear at a scheduled hearing, without good cause (as below); or

(3) A hearing has been held and a decision made.

8. Incomplete appeals. Upon receipt of an appeal request that fails to meet the requirements of this section and/or other applicable federal or state laws, regulations, and/or rules, the EHO or agency must, promptly and without undue delay, send written notice informing the affected party:

a. The appeal request has not been accepted;

b. The reasons for determining the appeal request incomplete;

c. If there is any cure for the defects in the appeal request and the timeline in which the appellant may submit an amended appeal.

9. Agency/program Specific Requirements. For both HSRI and Medicaid, appeals must be filed pursuant to §2.2.1(A)(4) of this Part within thirty (30) days of the contested agency action. The 30 days begins five (5) days after the mailing date of the notice of an intended agency action. See § 2.4 of this Part for special provisions related to the Office of Child Support Services and long-term care facility/resident actions.

2.2.2CONTINUATION OR REINSTATEMENT OF AID PENDING RESOLUTION OF AN APPEAL

A. An appellant may receive the continuation or reinstatement of eligibility or assistance in certain types of cases if an appeal is filed in the advance notice period, before an agency action takes effect. Requirements related to aid pending are as specified below:

1. Advance Notice Period. The State must institute aid pending in situations in which timely and adequate notice are not provided.

B. Agency Responsibilities. Upon determining a request for aid pending is valid, except for HSRI, a representative of the agency or EHO must provide information about the following:

1. Consequences - The person receiving aid pending must be advised of the consequences of reinstating/continuing assistance during the appeal. See table in §2.2.2(C) of this Part for an overview of possible consequences if an adverse action is upheld on appeal.

2. Scope and duration - At the time aid pending is initiated, the appellant must be informed that assistance will be continued until a hearing decision is rendered, unless:

a. A determination is made at the hearing that the sole issue is one of a change in state or federal law, regulation/rule or policy, as indicated in 42 C.F.R. § 431.220(a); or

b. Another agency change affecting the appellant's assistance occurs while the hearing decision is pending and the appellant fails to request a hearing on the second issue after notice of that change.

3. Agency/Program-specific provisions - The appellant must be provided with notification of any special provisions related to aid pending that may affect in any way the delivery of the assistance while the appeal is pending. Agencies shall also abide by the provisions set forth in § 2.4 of this Part.

C. Summary of Aid Pending - The following table summarizes aid pending requirements, responsibilities, and possible consequences by agency/program:

State Agency Administering Program	Name of Program	Advance Notice Period	Potential Consequence - Adverse Action Upheld
(a) Department of Human Services	General Public Assistance (GPA)	10 days from the mail date. Appeal request must be accompanied by or include a written statement asking specifically for continuation of GPA to stay the reduction, suspension, or discontinuance until the fair hearing decision is issued.	Repayment may be required.
(b) Department of Human Services	Supplemental Nutrition Assistance Program (SNAP)	10 days from the mail date	SNAP benefits discontinued at the end of the certification period. Recoupment initiated.
(c) Department of Human Services	Rl Works	10 days beginning on the fifth day after the date on the notice of intended action. If the advance notice period ends on a holiday or weekend, beneficiary is entitled to aid pending if appeal is received on the day after the holiday or weekend.	Repayment required and recoupment is initiated. For Rl Works participants, appeal period may count toward time-limits
(d) Department of Beliavioral Healthcare, Developmental Disabilities, and Hospitals	All programs and services	10 days beginning on the fifth day after the date on the notice of intended action
(e) Health Source Rl -health benefit exchange	Qualified Health Plans, Advance Premium Tax Credits and Cost Sharing Reductions, the Small Business Health Options Program	Within 30 days of the eligibility redetermination occurring	Reconciliation of advance receipt of premium tax credits which may require the repayment of advanced premium tax credits or otherwise impact a federal tax return. Payment of premium to carrier.
(f) Executive Office of Health & Human Services	All Medicaid	10 days beginning on the fifth day after the date on the notice of intended action	Repayment for Medicaid- funded services required. Recoupment or estate recovery initiated.
(g) Executive Office of Health and Human Services	Nursing facility and assisted living transfers/discharges	10 days beginning on the fifth day after the date on the notice of intended action

2.2.3Continuation or Reinstatement of Benefits After the Effective Date of Action

A. Where the beneficiary requests a hearing more than ten (10) days after the date of the intended action, the beneficiary's services may be continued or reinstated until a final agency decision is rendered after the hearing if the beneficiary provides verification, in the form of a signed statement with supporting documentation, of one of the following circumstances:

1. The beneficiary's life, health, or safety will be seriously impacted by the loss of benefits.

2. The beneficiary was unable to request a hearing before the date of action due to the beneficiary's disability or employment.

3. The beneficiary's caregiver or their authorized representative was unable to request a hearing before the date of action due to their health or employment.

4. The beneficiary did not receive the state's or designated service agencies notice prior to the effective date of the intended action.

B. If a Medicaid beneficiary is receiving aid pending, after appealing a decision that he/she is no longer Medicaid eligible, said beneficiary shall continue to receive the Medicaid benefits that were being received when the appeal request was filed.

2.2.4ALTERNATIVE DISPUTE RESOLUTION OPTIONS

A. State and federal laws require that public agencies make alternative informal and formal dispute resolution options available to an appellant.

B. The mix of informal and formal options is generally as follows with the exceptions noted:

1. Informal Dispute Resolution Options. Each agency provides appellants with one or more informal options for resolving an appeal while the hearing process goes forward. The informal dispute resolution process involves a discussion between the appellant and one or more representatives of the agency that took the action.

2. Voluntary - - Participation in informal resolution is entirely voluntary on the part of the appellant. If the informal resolution process is successful and the contested agency action does not advance to a hearing, the informal resolution decision is final and binding. Administrative hearing officers do not participate in informal settlement conferences.

3. Disposition Related to Agency Errors - When it is determined through the informal resolution process that an agency error was the basis for an action under appeal, the appeal may be disposed as follows:

a. Agency Response Amended. Supporting documentation from the affected party may be entered into the agency response and retained as part of the record.

b. Notice of Corrected Action. Until such time as the appellant receives the updated notice and the appropriate action is in effect, the appeal remains open.

c. Appeal Withdrawal. The appellant is required to withdraw the appeal even if it is determined during the informal resolution process that the original eligibility decision was incorrect.

C. Formal Dispute Resolution Options - An appellant may opt to by-pass the informal process entirely or proceed in incremental steps to the formal resolution options. The administrative fair hearing process is initiated when an appeal is filed and, as such, is the principal formal option.

D. Pre-hearing settlement conference - An appellant may choose to pursue a pre-hearing settlement conference as a formal dispute resolution option when an agency and circumstances allow. The Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (BHDDH) and the EOHHS often make this option available upon request to beneficiaries and providers. The pre-hearing settlement conference functions as follows:

1. Presiding Settlement Conference Officer. A pre-hearing settlement conference is presided over by an impartial hearing officer designated by the EHO. The presiding officer acts as a mediator between the appellant and agency and, in this capacity, endeavors to establish a settlement agreement, satisfactory to both parties, to serve as a disposition to the contested agency action.

2. Review of Case and Proposed Settlement. The presiding officer reviews the appeal and the agency's response and the terms of any proposals that may be offered to resolve the dispute with the agency and the appellant and/or their legal representatives.

3. Components of Settlement Agreement. The settlement agreement must contain the terms for resolving the appeal, implementing any corrective actions required, withdrawing the appeal and closing the contested agency action as outlined in § 2.3.3 of this Part.

4. Disposition of the Case. If accepted by all parties, the settlement agreement is final and binding and must be implemented in the terms established without due delay. If no agreement is reached, the contested agency action proceeds to a formal adjudication in an administrative fair hearing, as outlined § 2.3 of this Part.

E. Administrative Fair Hearing - The dominant formal dispute resolution mechanism is an administrative fair hearing as specified in detail in § 2.3 of this Part.

210 R.I. Code R. 210-RICR-10-05-2.2

Amended effective 7/22/2020