Common use of Eligibility Appeals Clause in Contracts

Eligibility Appeals. The Department of Economic Security has an Office of Appeals, which hears eligibility appeals for eligibility determinations made by DES employees. Eligibility appeals for eligibility determinations made by AHCCCS employees are heard by a separate agency, the Office of Administrative Hearings (OAH). Other than the two different offices the eligibility appeals process are essentially the same. Any differences are noted below. If a Childless Adult loses eligibility for any reason, they have 30 calendar days from the date the decision notice is mailed to request an appeal of the decision. A request for appeal can be submitted either verbally or in writing. The member may request to withdraw the hearing request at any time. Benefits will continue if the request for appeal is received within 10 calendar days from the date the decision notice is mailed. Benefits will not be continued if the action appealed is due solely to a change required by a change in federal or state law. Within 7 days from receipt of the appeal request at DES and within 10 days at AHCCCS, the DES or AHCCCS eligibility office schedules a pre-hearing conference and sends copies of the budget calculations, income screens, notices, and case notes to the member. The conference may be conducted by telephone at the request of the member. Within 10 calendar days of receipt of the appeal request, a DES or AHCCCS supervisor reviews the results of the pre-hearing conference and documents in the appeal packet the accuracy of the eligibility decision. When the pre-hearing conference may result in an informal resolution of the dispute at DES, a request to withdraw from the appeal is sent to the member. An informal resolution may happen when the decision is discussed with the member directly and the member agrees that the agency made the correct decision. A request to withdraw from the appeal is not sent to the member when the decision requires correction. When the review of the circumstances indicates that the case needs correction, DES sends the Request to Xxxxxx and Xxxxxx (FAA-1389A) form to the Office of Appeals. The case is not corrected until a response is received from the Office of Appeals or the Office of Administrative Hearings that indicates that the matter was vacated and remanded to the local office for correction. At AHCCCS, when the pre-hearing conference may result in an informal resolution of the dispute, a request to withdraw from the appeal is sent to the member. If a correction is needed, AHCCCS takes the action necessary to correct the adverse action being appealed. When the completed Voluntary Withdrawal from Appeal form is received, it is sent electronically to OAH with a request to vacate the appeal. When a resolution is not reached during the pre-hearing conference, DES or AHCCCS continues processing the request for appeal. Appeals are scheduled to allow for a decision to be rendered within 90 days from the request for appeal. Appeals are scheduled not fewer than 20, nor more than 45, calendar days from the date the request is filed. The member may request less than 20 calendar days notice in order to expedite the appeal. Appeals may be conducted by phone when mutually agreed on by the member and the Office of Appeals for DES or the Office of Administrative Hearings for AHCCCS. The member is afforded the same rights as members who attend face-to- face hearings. The member presents the facts and knowledge of the case, and has an opportunity to address witnesses, present evidence, advance arguments, refute testimony or evidence, and examine evidence introduced by any party at the hearing. The Office of Appeals for DES or the AHCCCS Director, for AHCCCS appeals, notifies the member of the appeal decision. If the appeal decision is unfavorable to the member, he/she may request an appeals board review of the decision. If the Appeals Board decision is unfavorable to the member, he/she may request a Judicial Review of the Appeals Board decision. For AHCCCS, OAH makes a written recommended decision within 20 days from the day of the hearing. The AHCCCS Director reviews the recommendation and issues a written decision to the member within 30 days. If the decision is unfavorable to the member, the member may request a re-hearing. Local eligibility offices are required to take action to implement all appeal decisions and remands within 10 days. Based on historical appeals data relating to changes in eligibility, copayments, etc., the State has seen a minimal increase in the number of appeals. Given the other elements in the phase out plan, such as specific community outreach, the ex parte process and exceptions made to target particular groups, DES does not expect a heavy influx of appeal requests. There is a significant amount of variation regarding total number of appeals received in any one month. Thus, DES is staffed in such a way as to deal with peak highs and lows. Eligibility appeals are given priority and appeals from providers and others are secondary. Also, DES provides a quarterly report on number of hearing requests, number of decisions and timeliness that AHCCCS monitors. The State does not shift staff to address high/low peaks. The Arizona Office of Administrative Hearings conducts hearings on a number of different subjects, in addition to eligibility appeals. The State has a longstanding agreement that eligibility appeals are given priority. This agreement – that eligibility cases are a priority for the State to remain in compliance with federal law – is included in AHCCCS’ Intergovernmental Agreement with the Office of Administrative Hearings. In the event that the State receives a significant increase of appeals in a given month, the State is aware of its responsibilities to process eligibility appeals timely and would appropriately allocate resources to that end.

Eligibility Appeals. The Department of Economic Security has an Office of Appeals, which hears eligibility appeals for eligibility determinations made by DES employees. Eligibility appeals for eligibility determinations made by AHCCCS employees are heard by a separate agency, the Office of Administrative Hearings (OAH). Other than the two different offices the eligibility appeals process are essentially the same. Any differences are noted below. If a Childless Adult loses eligibility for any reason, they have 30 calendar days from the date the decision notice is mailed to request an appeal of the decision. A request for appeal can be submitted either verbally or in writing. The member may request to withdraw the hearing request at any time. Benefits will continue if the request for appeal is received within 10 calendar days from the date the decision notice is mailed. Benefits will not be continued if the action appealed is due solely to a change required by a change in federal or state law. Within 7 days from receipt of the appeal request at DES and within 10 days at AHCCCS, the DES or AHCCCS eligibility office schedules a pre-hearing conference and sends copies of the budget calculations, income screens, notices, and case notes to the member. The conference may be conducted by telephone at the request of the member. Within 10 calendar days of receipt of the appeal request, a DES or AHCCCS supervisor reviews the results of the pre-hearing conference and documents in the appeal packet the accuracy of the eligibility decision. When the pre-hearing conference may result in an informal resolution of the dispute at DES, a request to withdraw from the appeal is sent to the member. An informal resolution may happen when the decision is discussed with the member directly and the member agrees that the agency made the correct decision. A request to withdraw from the appeal is not sent to the member when the decision requires correction. When the review of the circumstances indicates that the case needs correction, DES sends the Request to Xxxxxx and Xxxxxx (FAA-1389A) form to the Office of Appeals. The case is not corrected until a response is received from the Office of Appeals or the Office of Administrative Hearings that indicates that the matter was vacated and remanded to the local office for correction. At AHCCCS, when the pre-hearing conference may result in an informal resolution of the dispute, a request to withdraw from the appeal is sent to the member. If a correction is needed, AHCCCS takes the action necessary to correct the adverse action being appealed. When the completed Voluntary Withdrawal from Appeal form is received, it is sent electronically to OAH with a request to vacate the appeal. When a resolution is not reached during the pre-hearing conference, DES or AHCCCS continues processing the request for appeal. Appeals are scheduled to allow for a decision to be rendered within 90 days from the request for appeal. Appeals are scheduled not fewer than 20, nor more than 45, calendar days from the date the request is filed. The member may request less than 20 calendar days notice in order to expedite the appeal. Appeals may be conducted by phone when mutually agreed on by the member and the Office of Appeals for DES or the Office of Administrative Hearings for AHCCCS. The member is afforded the same rights as members who attend face-to- to­ face hearings. The member presents the facts and knowledge of the case, and has an opportunity to address witnesses, present evidence, advance arguments, refute testimony or evidence, and examine evidence introduced by any party at the hearing. The Office of Appeals for DES or the AHCCCS Director, for AHCCCS appeals, notifies the member of the appeal decision. If the appeal decision is unfavorable to the member, he/she may request an appeals board review of the decision. If the Appeals Board decision is unfavorable to the member, he/she may request a Judicial Review of the Appeals Board decision. For AHCCCS, OAH makes a written recommended decision within 20 days from the day of the hearing. The AHCCCS Director reviews the recommendation and issues a written decision to the member within 30 days. If the decision is unfavorable to the member, the member may request a re-hearing. Local eligibility offices are required to take action to implement all appeal decisions and remands within 10 days. Based on historical appeals data relating to changes in eligibility, copayments, etc., the State has seen a minimal increase in the number of appeals. Given the other elements in the phase out plan, such as specific community outreach, the ex parte process and exceptions made to target particular groups, DES does not expect a heavy influx of appeal requests. There is a significant amount of variation regarding total number of appeals received in any one month. Thus, DES is staffed in such a way as to deal with peak highs and lows. Eligibility appeals are given priority and appeals from providers and others are secondary. Also, DES provides a quarterly report on number of hearing requests, number of decisions and timeliness that AHCCCS monitors. The State does not shift staff to address high/low peaks. The Arizona Office of Administrative Hearings conducts hearings on a number of different subjects, in addition to eligibility appeals. The State has a longstanding agreement that eligibility appeals are given priority. This agreement – that eligibility cases are a priority for the State to remain in compliance with federal law – is included in AHCCCS’ Intergovernmental Agreement with the Office of Administrative Hearings. In the event that the State receives a significant increase of appeals in a given month, the State is aware of its responsibilities to process eligibility appeals timely and would appropriately allocate resources to that end.