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c) Included in the program’s administrative vendor contract is a section on reviewing appeals. In addressing the need for expedited review when there is an immediate need for health services, a contractual provision requires the administrative vendor to forward all appeals in need of immediate review to the Managed Risk Medical Insurance Board within five (5) business days. d) As required in 42 CFR 457.1170, California provides enrollees the opportunity for continuation of enrollment pending the completion of review of a termination of enrollment, including a decision to disenroll for failure to pay cost sharing. Prior to disenrollment, enrollees are notified of the impending termination, the reason for such termination, and a pre-printed form in which to request continued enrollment and to provide the necessary information or explanation as to why termination should not occur. This provision of the Healthy Families Program was implemented in February 2003. e) California already provides written notification to applicants and enrollees on all decisions made. In addition, as explained in a. and d. above, all decisions which have a negative impact on an applicant or enrollee include instructions on how to appeal the decision and request continued enrollment if the applicant or enrollee believes the decision is incorrect. f) California provides all review decisions in writing. g) California affirms that each applicant or enrollee has the right to represent him or herself or choose a representative, the right to review his or her file and other relevant information and the right to participate fully in the review process. In reviewing the specific requirements of 42 CFR 457.1140(d)(1)-(3) California will modify its current appeal language to include an affirmative statement regarding an applicant’s or enrollee’s right to representation and opportunity to review his or her records. This modification is in process with California’s new administrative vendor and should be complete by March 2004. California complies with the requirement to allow an applicant or enrollee to participate fully in the review process. Any notification of an appeal able determination includes full notification of appeal rights and instructs the applicant or enrollee that he or she can submit additional information for review. Health Services Matters Effective Date: Approval Date: November 1, 2009 HFP Family Contribution Increase November 1, 2009 HFP Co-Payment Increase November 1, 2009 HFP Limited Dental Plan Choice for New Subscribers

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