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Effective Date: April 1, 2009
Approval Date: ____________ 60
themselves or have representatives in the process at the external appeals level. Plan A uses the Medicaid Fair Hearing process for health services matters.
The State assures that enrollees in Plans A, B, C and D have the opportunity to timely review of their files and other applicable information relevant to the review of the decision. While this is assured at each level of review, members will be notified of the specific timeframes for the appeals process, once an external appeal is filed.
The State assures that enrollees have the opportunity to fully participate in the review process, whether the review is conducted in person or in writing. Enrollees in Plans B, C and D have the opportunity to represent themselves or to have representation of their choosing at the HMO grievance and the external levels.
The State assures that reviews that are not expedited due to an enrollee’s medical condition will be completed within 90 calendar days of the date a request is made.
The State assures that reviews that are expedited due to an enrollee’s medical condition are completed within 72 hours of the receipt of the request.
Premium Assistance Programs
12.3 If providing coverage through a group health plan that does not meet the requirements of 42 CFR 457.1120, please describe how the state will assure that applicants and enrollees have the option to obtain health benefits coverage other than through the group health plan at initial enrollment and at each redetermination of eligibility.
Not applicable.