Who Has the Final Say? Appealing Medicaid Eligibility Decisions in Federal Marketplace States

The ACA’s “no wrong door” enrollment policy requires Medicaid agencies and marketplaces to work together to ensure every consumer is enrolled in the appropriate insurance affordability program. This goal of a seamless enrollment experience for consumers extends to the eligibility determination appeals process as well.
State Medicaid agencies have existing appeals processes and the new marketplaces are required to have appeals processes that coordinate with the Medicaid agencies. Under the ACA, in all states—regardless of their marketplace models—the state Medicaid agency decides where Medicaid appeals will be handled. States can choose from three options:

1. to process all Medicaid appeals within the Medicaid agency;
2. to delegate all Medicaid appeals to the Marketplace; or
3. to delegate all Medicaid appeals to a third-party state agency.

Many states with FFMs are choosing the entity that makes the final Medicaid eligibility determination to also handle any appeals. For more information about how Medicaid agencies in federally facilitated marketplace (FFM) and state partnership marketplace (SPM) states can coordinate Medicaid eligibility decisions with the marketplace, see this earlier State Refor(u)m blog post.
If a state chooses to delegate the Medicaid appeals process, it must do so through a formal process that establishes operational protocols and oversight responsibilities. All three options are being taken up by different states.
Appeals done by the state Medicaid agency
In states that choose this option, the Medicaid agency will hear appeals for all consumers appealing eligibility determinations for Medicaid. The Medicaid agency can also choose to adopt an informal resolution process, where consumers can work with staff to determine the accuracy of documents or submit updated information.  If the consumer is not satisfied with the result of the informal resolution, the case will then continue through the formal appeals process.

• New Hampshire is a SPM state that has decided to both make the final determination of Medicaid eligibility and process appeals within the Medicaid agency. Currently, the Administrative Appeals Unit of the state Department of Health and Human Services hears appeals for all programs, such as Medicaid and the Supplemental Nutrition Assistance Program (SNAP), and it will remain this way.

Appeals delegated to the FFM
States that are using the FFM to make the final determination of eligibility for Medicaid may choose to delegate appeals to the FFM. The federal Department of Health and Human Services (HHS) will hear appeals for both Medicaid and Advanced Premium Tax Credit (APTC) eligibility determinations. For consumers in states that delegate to HHS, informal resolution is a required first step, but consumers maintain the right to a formal hearing if unsatisfied with informal resolution. Consumers also maintain a right to appeal to the state Medicaid agency, even if the state delegates appeals to HHS.

• Montana, which uses the FFM to conduct the final determination of Medicaid eligibility, has opted to delegate appeals to the federal marketplace. The state Medicaid agency decided that the FFM is in the best position to process appeals because it can show what data were used to determine Medicaid eligibility.

Appeals delegated to a third-party state agency
State Medicaid agencies may choose to delegate Medicaid appeals to a third-party state agency using authority in the Intergovernmental Cooperation Act of 1968 (ICA). In states that delegate to a third-party agency using this process, a consumer has no right to appeal to the Medicaid agency.

• Illinois, which is an SPM state and has elected to conduct the final determination of Medicaid eligibility, has chosen to divide the appeals process between two state agencies depending on whether consumers are applying for multiple support programs. Specifically, the Medicaid agency, the Department of Healthcare and Family Services, will handle appeals for consumers who have applied only for medical assistance. For Medicaid appeals that also involve applications for social service programs such as SNAP, Temporary Assistance for Needy Families (TANF) or other support programs, the Illinois Department of Human Services will handle these appeals as well as those involving disability determinations.

How is your state Medicaid agency handling the appeals process?  Tell us in a comment below.