DHS extends Medicaid appeal window to 35 days, will continue services during appeals

The Department of Human Services told a legislative committee it will extend the time enrolled Medicaid beneficiaries have to appeal adverse actions from 10 days to 35 days and will continue beneficiaries’ services while appeals are pending.

Veil Smith, deputy director for the Division of Medical Services at the Department of Human Services, said the change “extends the time that Medicaid beneficiaries can appeal on, an adverse action from 10 days to 35 days.” She added that the rule change also “allows for the continuation of services until a decision has been made.” The department said the change applies only to enrolled Medicaid beneficiaries facing an adverse action, such as a loss of eligibility or a decrease in services.

DHS said the change is needed to comply with federal regulations that bar terminating or reducing services when a beneficiary files an appeal before the adverse action date and require continuation of services until a hearing decision is made. The agency estimated a fiscal impact of about $40,700,000, with roughly $6,000,000 coming from the state share of that total.

Committee members asked procedural questions about where past-member appeals are handled; DHS counsel Brett Hayes said appeals for past members are handled through a separate process. No formal roll-call vote was recorded in the transcript; the chair closed the item by stating the rule was reviewed.

The change will be implemented via a provider-manual amendment and affects only beneficiaries enrolled in Medicaid at the time of the adverse action. DHS did not provide a specific implementation date during the presentation.

DHS offered to take follow-up questions from committee members by phone and in meetings; the committee did not record additional directions beyond reviewing the rule.

The committee moved on to subsequent items after the presentation.