PHLP Advocacy Results in Revamped CHC Grievance Decision Notices

The Office of Long-Term Living (OLTL), which oversees the Community HealthChoices (CHC) program, recently took a much-needed step to help clarify how participants can exercise their right to continue receiving health care services while appealing a service reduction or termination.   

When a health plan proposes to reduce or stop authorizing a service – like personal assistance services or a medication – participants have a right to continue getting that service while they appeal the health plan’s decision. This right is often called, “aid paid pending.” Because managed care appeals have multiple steps and aid paid pending is only available for appeals made within a very short time frame after the denial, PHLP has seen many people lose their right to continue receiving services while making their appeals due to appealing too late.   

There are three appeals a participant can take when a health plan denies a service or item.  The first is a “grievance,” which is an appeal to the health plan to reverse its decision. If the grievance is unfavorable, the participant has a choice of next appeals: they can request a fair hearing with a state administrative law judge, an external review by an independent medical professional, or both. To get aid paid pending through both the external review and fair hearing, the participant must request both appeals within ten days (15 during the COVID public health emergency) of the date on the grievance decision. Unfortunately, many people request only an external review at this stage, thinking that if the external review decision is unfavorable, they can then request a fair hearing afterwards and continue getting services. This is not the case. PHLP has fielded numerous calls from people in the CHC program who initially chose only to pursue an external review, lost that external review, requested a fair hearing and then were left without their services while waiting months for the fair hearing to be scheduled.  

PHLP raised to OLTL our concerns regarding the widespread confusion around aid paid pending after a grievance decision. We proposed several solutions, including treating a request for external review also as a fair hearing request and clarifying the need to request both appeals at the same time on the grievance decision notices.  Ultimately, OLTL revised the grievance decision notices to include language emphasizing the need to request both an eternal review and fair hearing at the same time in order to receive aid paid pending.

We hope both the Office of Medical Assistance Programs (OMAP) and the Office of Mental Health and Substance Abuse Services (OMHSAS), which respectively oversee the Physical HealthChoices and Behavioral HealthChoices health plans, will follow OLTL’s lead and similarly adjust their grievance decision notices going forward.