Appeal type: Supplemental Benefit
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.
You asked the Plan to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services. The Plan denied your request. The Plan says for an enrollee to be a candidate for these benefits he/she needs to have one or more of the eligible chronic conditions documented in the Evidence of Coverage for 2020 and require intensive care coordination, and must be at high risk of hospitalizations or adverse health outcomes. The enrollee does not meet any of these criteria and for this reason the benefits were denied.
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that you do not have one or more of the qualifying diagnoses, you do not require intense care coordination, and you have no high risk for hospitalizations or high risk for adverse health outcomes. Based on this information, we decided that the Plan's rules for coverage of a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services have not been met. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services. We decided that the Plan does not have to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.
You asked the Plan to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services. The Plan denied your request. The Plan says for an enrollee to be a candidate for these benefits he/she needs to have one or more of the eligible chronic conditions documented in the Evidence of Coverage for 2020 and require intensive care coordination, and must be at high risk of hospitalizations or adverse health outcomes. The enrollee does not meet any of these criteria and for this reason the benefits were denied.
The Plan contract says that, in order to be eligible for an allowance, you must have one or more comorbid and medically complex chronic conditions that are life-threatening or significantly limit your health or general functioning. In addition, you must have a high risk of hospitalization or other adverse health outcomes; and must require intensive care coordination. We looked at the file and the Plan's rules. The file shows that you do not have one or more of the qualifying diagnoses, you do not require intense care coordination, and you have no high risk for hospitalizations or high risk for adverse health outcomes. Based on this information, we decided that the Plan's rules for coverage of a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services have not been met. Therefore, we decided that the Plan does not have to pre-approve a debit card for an allowance for transportation for non-medical needs, healthy food purchases and/or electricity, water and/or phone bill payments and home assistance services.