CLIENTS CAN KEEP SERVICES DURING AN APPEAL

Medicaid recipients, who file requests for a fair hearing within 10 days of notice of a DMA denial, reduction, or modification of services, can receive aid pending appeal. The success of appeals and the ability to get aid pending appeal depend upon the cooperation of treating professionals.

WHO CAN GET AID PENDING APPEAL?

Any Medicaid recipient who files a timely request for a fair hearing.

WHAT IF THE PARTNERSHIP OR AN HMO ADMINISTRATOR DENIES, REDUCES, OR MODIFIES THE SERVICES?

Because DMA has delegated its authority to the Partnership and HMOs, denial by the latter entities constitutes denial by DMA.

WHAT IF THE PARTNERSHIP OR HMO ADMINISTRATOR DENIES, REDUCES, OR MODIFIES SERVICES AND THE PROVIDER DOESN'T OBJECT?

Medicaid regulations specify that any services that require prior authorization must be requested by the provider in order to trigger the right of aid pending appeal. If a provider agrees to a reduction of or restriction on services, the question is raised whether this requirement is met. In addition, if the provider agrees to the change in treatment, DMA will not send a notice to the client and the client will not be aware of her appeal rights. Advocates will argue that the financial ties that bind providers to HMOs and the Partnership are such that the failure of a provider to request a continuation of services is equivalent to a DMA denial. Nevertheless, it is the better practice for clinicians to note their objections to changes in services suggested by the HMO/Partnership.

WHEN MUST THE APPEAL BE FILED?

The Board of Hearings within the DMA or HMO must receive a written request for a fair hearing within 10 days of the mailing of the notice of a DMA decision to suspend, reduce, terminate, or restrict services. In those instances described above when notice of denial is not mailed, the request for aid pending appeal should be filed within 10 days of when the client is first notified of the change in services.

DOES THE APPEAL HAVE TO BE MADE TO DMA TO GET AID PENDING APPEAL?

No. DMA is requiring HMO clients to appeal first to the HMO in question. Partnership clients may appeal directly to the Board of Hearings, 2 Boylston St., Boston, MA 02116, fax (617) 521-6462. Wherever the appeal is initiated, DMA agrees that the client has the right to aid pending appeal. However, since MCOs are not used to providing services during an appeal process, clients and their advocates should be sure to specify that they are requesting "aid pending appeal."

WHAT ARE THE CHANCES OF A SUCCESSFUL APPEAL?

Of course, the odds of winning an appeal depend upon the facts of the case. However, those odds are much worse if the client's clinician does not support her appeal.

WHAT IF THE CLIENT LOSES THE APPEAL?

If the client loses the appeal, DMA can seek to recoup the costs of the services rendered during the appeal process. These costs are recouped from the client, not the provider. To date, DMA rarely pursues recoupment except in cases of criminal fraud.

BOTTOM LINE:

Clients have the right to request aid pending appeal any time their treatment plans are changed. Ethical clinicians should support a client's appeal by insisting on continuation of services.
If you or a family member have difficulty getting aid pending appeal, please call: Mental Health Legal Advisors Committee in Massachusetts (617) 338-2345 ext. 28 or (800) 342-9092

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