1706 Changes Received During the Appeal Process

Revised 07/10/2020

Policy

During the appeal process, a new change may occur before the hearing decision is made that affects the customer’s eligibility, level of services, premium, or share of cost amount.

The table below explains how changes are processed when they are received during the appeal process.

If...	Then...
The customer is approved for continued benefits during the appeal process; AND The reported change will result in an adverse action.	The change is not processed until the hearing process ends.
The customer is approved for continued benefits during the appeal process; AND The change results in a non-adverse action	The change is processed and the customer is sent a new decision letter.
The customer does not have continued benefits.	The change is processed and the customer is sent a new decision letter no matter what the eligibility result is.

See Examples - Changes Reported Before the Hearing is Decided

Definitions

Term

Definition

Adverse Action

In general, an adverse action is any action to:

Deny, suspend or stop MA;
Increase the customer’s share of cost or premium amount; or
Reduce services or benefits.

NOTE This includes actions to approve emergency services only instead of full MA coverage and changes from full MA coverage to emergency services.

Notice of Action

A notice that explains the action that has been taken on a customer’s case.

Agency Responsibilities

Advance notice is given whenever an adverse action is taken before the decision on the original issue.

Customer Rights and Responsibilities

The customer may ask for a fair hearing on the new adverse action and has 35 days from the new notice to file the request.

Legal Authority

This requirement applies to the following programs:

Program

Legal Authorities

All Programs

42 CFR 431.231

AAC R9-34-114