*** The Health Care Programs Manual (HCPM) has been replaced by the Minnesota Health Care Programs Eligibility Policy Manual (EPM) as of June 1, 2016. Please refer to the EPM for current health care program policy information. ***
Effective: May 1, 2009 |
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27.10 - Continued Benefits |
Archived: June 1, 2016 (Previous Version) |
Enrollees who submit appeal requests within the time frames shown on this page may continue to receive health care coverage at the same benefit level while the appeal is pending. If a client does not want benefits to continue at the same level, require a written request to continue benefits at the lower level or to end benefits.
Do not continue coverage during an appeal to district court unless the final Department order specifically directs you to continue coverage.
Continue benefits at the level the enrollee received before the action that caused the appeal, if the agency or DHS receives the appeal request by the later of these dates:
l Before the effective date of the action.
l Within 10 days after the notice mailing date.
Note: An appeal is timely for purposes of continued benefits when the agency receives it on the next working day if the end of a notice period is on a weekend or holiday.
Notify clients that they must repay benefits continued or overpaid while an appeal is pending if they lose their appeal. This information is on the Appeal to State Agency (DHS-0033) and on the back of notices.
Do not continue benefits if the client makes a written request to discontinue the coverage.
The client must continue to pay premiums or meet a spenddown, if applicable. Except for MinnesotaCare appeals based on cancellation for non-payment, the due date for all premiums owed is the later of these dates:
l Before the proposed date of the action.
l Within 10 days after the date of the mailing of the notice.
Example:
MinnesotaCare sends Rob a cancellation notice on December 15. The cancellation reason is the availability of other insurance. Rob appeals the January 1 cancellation. To continue benefits while the appeal is pending, he must pay the January premium by the last working day in December.
For more information about cancellation for non-payment and reinstatement, see:
l MinnesotaCare Reinstatement.
l MinnesotaCare Four Month Penalty.
Continue to process case changes if benefits continue while the appeal is pending. The household must continue to report changes and return renewals.
Notify the client of the adverse action if there is a negative eligibility change not related to the appeal issue. Take the action unless the client appeals this separate action.
Example:
An MA household with increased income appeals an increased spenddown. At the household's request, coverage continues at the old spenddown amount while the appeal is pending. The household does not return a renewal that is due before the hearing.
Action:
Send a notice of termination for failure to comply with renewal requirements. Terminate MA unless the household returns a completed renewal before the effective date of termination. Do not terminate MA if the client appeals this termination action.
Example:
A MinnesotaCare client appeals the removal of a household member from coverage based on the availability of other insurance. At the client's request, coverage continues for the entire household while the appeal is pending. The household must continue to pay the premium for the entire household, including the member with the other insurance. While the appeal is pending, a new member with income moves into the household resulting in an increased premium.
Action:
Increase the premium unless the household files a separate appeal of that action.
A client must continue paying the premium amount in effect before the increase to continue benefits while appealing the premium increase. The client must pay the difference for the months the appeal was pending if the appeal decision upholds the increased premium.
Example:
When MinnesotaCare processes the renewal for the McDonald family, the premium
increases from $49 to $82 effective February 1. Mr. McDonald appeals the
premium increase.
Action:
Continue coverage with the $49 premium while the appeal is pending. The appeal decision upholds the increased premium effective February 1. Require the McDonalds to pay the $33 difference for all months that the appeal was pending.