Jack Regenbogen previously served as Senior Attorney at Colorado Center on Law and Policy.

Oct 20, 2016

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Health care problem warrants proper notice

by | Oct 20, 2016

When a Medicaid client receives an unexpected letter from the State of Colorado, it often marks the beginning of a trying and potentially life-altering ordeal. These letters, sometimes referred to as Notices of Action (NOAs), are mailed to clients when health care benefits are being reduced or terminated.

While these letters are a source of stress for their recipients, they are also a necessary component of administering the Medicaid program, since they provide clients with advance notice of the reduction, termination, or suspension of their benefits. The letters are intended to inform clients of any changes in their eligibility and to provide them with information about how to appeal the loss of their benefits if they believe the action is unjustified. The NOA is supposed to ensure that Medicaid clients are afforded their due-process rights guaranteed by U.S. Constitution.

In practice, NOAs are often vague and confusing. Most do not specify why benefits are being terminated or reduced, so Medicaid clients don’t always know whether they should challenge the decision. Furthermore, without proper notice, those who appeal may be unable to fully prepare their case.

Problems with notices can cause eligible Medicaid clients to unjustifiably lose their benefits. When this happens, under the best-case scenario, the client could re-apply for benefits, although the process of reapplying causes a delay in coverage and is more expensive to the state than simply maintaining coverage for those who are eligible. For clients who rely on daily services, the loss of Medicaid for even one day can result in serious health problems.

In light of these all-too-common notification issues, Colorado legislators formed an interim committee to address shortcomings in Medicaid client correspondence and NOAs. This Interim committee held three hearings over the summer, which included testimony from the Colorado Center on Law and Policy, the Colorado Cross-Disability Coalition (CCDC), and the Colorado Department of Health Care Policy and Financing.

During these hearings, CCLP and CCDC recommended several solutions that were developed into four bills, all of which were approved by the committee with bipartisan support. If the General Assembly passes these recommendations into law during the 2017 legislative session, these changes would significantly improve client correspondence and reduce the risk of clients losing coverage due to inadequate, confusing or uninformative letters.

Here is a brief summary of the bills approved by the interim committee and what they intend to accomplish:

  • Bill A would make improvements to an online appeals page designed to let clients submit additional documents that are relevant to their case. Due to technical limitations that affect Colorado’s administrative judicial website, some Medicaid clients have experienced difficulties providing adequate documentation for their appeal. In addition, some clients have reported that their right to receive continuing benefits pending the appeal has not been honored when they sought an appeal online. Bill A would allow Medicaid clients to submit additional documents relevant to their appeal and clarify that clients have the right to continuing benefits regardless of whether they appeal online or through other means. Additionally, Bill A would provide a “check box” on an appeal form to let clients note if they need special accommodations in an appeal hearing, such as an interpreter or ADA accommodations.
  • Bill B would strengthen the Administrative Law Judge’s role in safeguarding the rights of Medicaid clients. Currently, clients are able to question the sufficiency of their notice at an appeal hearing if they believe it is confusing or inadequate. If a judge finds that the notice is inadequate, the client can retain coverage until the state provides a more detailed explanation about why the benefits are being terminated. This procedural remedy gives clients an opportunity to understand why their health coverage is threatened and to prepare an appropriate response. Unfortunately, most Medicaid clients are not represented by an attorney and many are unaware they can require the state to provide more information about the basis for the decision and better prepare to challenge the proposed action. Bill B would rectify this problem, ensuring that an administrative law judge would automatically review the sufficiency of NOAs at the beginning of each appeal hearing. If a judge finds that a notice does not provide an adequate explanation, the client could elect to receive an improved notice, or they could choose to proceed with their hearing. The proposed legislation would help ensure that the right to adequate notice exists not only in theory, but in reality.
  • To prevent Medicaid notification issues from reoccurring, Bill C would direct the state to audit communications with Medicaid clients. These audits, which would take place in 2020 and 2023, would review notices for their legal sufficiency, clarity and accuracy. The audit findings, conclusions and recommendations will be presented to legislative committees, which can then consider whether the results warrant further reforms. The audits are a crucial component of confirming the successful implementation of any improvements that are made to Medicaid notices. Bill C would also help lawmakers assess how the reforms are working and enable them to draft legislative remedies to improve notification processes in the future.
  • Bill D aims to make notices more understandable, comprehensive and helpful. In particular, this bill would require plain-language statements explaining the loss or reduction of benefits while citing specific examples of the type of documentation that could help clients demonstrate their benefits should remain unchanged. For example, if a client needed to offer proof of income, the notice would list the types of documents (such as paycheck stubs) that the client could provide. Under the bill, notices would also include the client’s information relevant to their Medicaid eligibility, such as their recorded income. This information will help clients determine whether the loss of their benefits could be contested.

Collectively, these four proposals will help ensure that Medicaid clients do not lose access to health care due to the shortcomings in the current notification process.

While the interim committee only focused on Medicaid correspondence, these proposed improvements are needed in other essential public benefit programs. Whether health care, food, child care or financial assistance, a person’s access to public benefits should not be jeopardized by an ambiguous or confusing letter.

CCLP is proud to be supporting these four proposals during the 2017 legislative session.

– Jack Regenbogen

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