Source: https://www.ecfr.gov/cgi-bin/text-idx?node=sp45.1.155.f&rgn=div6
Timestamp: 2020-04-03 05:33:34
Document Index: 622631323

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Title 45 → Subtitle A → Subchapter B → Part 155 → Subpart F
PART 155—EXCHANGE ESTABLISHMENT STANDARDS AND OTHER RELATED STANDARDS UNDER THE AFFORDABLE CARE ACT
Source: 78 FR 54136, Aug. 30, 2013, unless otherwise noted.
In addition to those definitions in §§155.20 and 155.300, for purposes of this subpart and §155.740 of subpart H, the following terms have the following meanings:
Appeal record means the appeal decision, all papers and requests filed in the proceeding, and, if a hearing was held, the transcript or recording of hearing testimony or an official report containing the substance of what happened at the hearing, and any exhibits introduced at the hearing.
Appeal request means a clear expression, either orally or in writing, by an applicant, enrollee, employer, or small business employer or employee to have any eligibility determination or redetermination contained in a notice issued in accordance with §155.310(g), §155.330(e)(1)(ii), §155.335(h)(1)(ii), §155.610(i), §155.715(e) or (f), or §155.716(e) reviewed by an appeals entity.
Appeals entity means a body designated to hear appeals of eligibility determinations or redeterminations contained in notices issued in accordance with §155.310(g), §155.330(e)(1)(ii), §155.335(h)(1)(ii), §155.610(i), §155.715(e) and (f), or §155.716(e).
Appellant means the applicant or enrollee, the employer, or the small business employer or employee who is requesting an appeal.
De novo review means a review of an appeal without deference to prior decisions in the case.
Evidentiary hearing means a hearing conducted where evidence may be presented.
Vacate means to set aside a previous action.
[78 FR 54136, Aug. 30, 2013, as amended at 83 FR 17063, Apr. 17, 2018]
(iii) A determination of eligibility for an enrollment period, made in accordance with §155.305(b);
(3) A failure by the Exchange to provide timely notice of an eligibility determination in accordance with §155.310(g), §155.330(e)(1)(ii), §155.335(h)(1)(ii), or §155.610(i); and
(4) A denial of a request to vacate dismissal made by a State Exchange appeals entity in accordance with §155.530(d)(2), made under paragraph (c)(2)(i) of this section; and
(5) An appeal decision issued by a State Exchange appeals entity in accordance with §155.545(b), consistent with §155.520(c).
(h) Electronic requirements. If the Exchange appeals entity cannot fulfill the electronic requirements of subparts C, D, F, and H of this part related to acceptance of telephone- or Internet-based appeal requests, the provision of appeals notices electronically, or the secure electronic transfer of eligibility and appeal records between appeals entities and Exchanges or Medicaid or CHIP agencies, the Exchange appeals entity may fulfill those requirements that it cannot fulfill electronically using a secure and expedient paper-based process.
[78 FR 54136, Aug. 30, 2013, as amended at 79 FR 30349, May 27, 2014; 81 FR 12344, Mar. 8, 2016; 81 FR 94179, Dec. 22, 2016]
(a) Agreements. The appeals entity or the Exchange must enter into agreements with the agencies administering insurance affordability programs regarding the appeals processes for such programs as are necessary to fulfill the requirements of this subpart. Such agreements must include a clear delineation of the responsibilities of each entity to support the eligibility appeals process, and must—
(3) Comply with the requirements set forth in—
(i) 42 CFR 431.10(d), if the state Medicaid agency delegates authority to hear fair hearings under 42 CFR 431.10(c)(ii) to the Exchange appeals entity; or
(ii) 42 CFR 457.348(b), if the state CHIP agency delegates authority to review appeals under §457.1120 to the Exchange appeals entity.
(b) Coordination for Medicaid and CHIP appeals. (1) Where the Medicaid or CHIP agency has delegated appeals authority to the Exchange appeals entity consistent with 42 CFR 431.10(c)(1)(ii) or 457.1120, and the Exchange appeals entity has accepted such delegation—
(i) The Exchange appeals entity will conduct the appeal in accordance with—
(c) Data exchange. The appeals entity must—
(1) Ensure that all data exchanges that are part of the appeals process, comply with the data exchange requirements in §§155.260, 155.270, and 155.345(i); and
(b) General content on right to appeal and appeal procedures. Notices described in paragraph (a) of this section must contain—
(1) Must accept appeal requests submitted—
(D) That, in the event the appeal request is not valid due to failure to submit by the date determined under paragraph (b) or (c) of this section, as applicable, the appeal request may be considered valid if the applicant or enrollee sufficiently demonstrates within a reasonable timeframe determined by the appeals entity that failure to timely submit was due to exceptional circumstances and should not preclude the appeal.
(a) Dismissal of appeal. The appeals entity must dismiss an appeal if the appellant—
(1) Withdraws the appeal request in writing or by telephone, if the appeals entity is capable of accepting telephonic withdrawals.
(i) Accepting telephonic withdrawals means the appeals entity—
(A) Records in full the appellant's statement and telephonic signature made under penalty of perjury; and
(B) Provides a written confirmation to the appellant documenting the telephonic interaction.
(2) Fails to appear at a scheduled hearing without good cause;
(3) Fails to submit a valid appeal request as specified in §155.520(a)(4); or
(4) Dies while the appeal is pending, except if the executor, administrator, or other duly authorized representative of the estate requests to continue the appeal.
(b) Notice of dismissal to the appellant. If an appeal is dismissed under paragraph (a) of this section, the appeals entity must provide timely written notice to the appellant, including—
(1) The reason for dismissal;
(2) An explanation of the dismissal's effect on the appellant's eligibility; and
(3) An explanation of how the appellant may show good cause why the dismissal should be vacated in accordance with paragraph (d) of this section.
(c) Notice of the dismissal to the Exchange, Medicaid, and CHIP. If an appeal is dismissed under paragraph (a) of this section, the appeals entity must provide timely notice to the Exchange, and to the agency administering Medicaid or CHIP, as applicable, including instruction regarding—
(1) The eligibility determination to implement; and
(2) Discontinuing eligibility provided under §155.525, if applicable.
(d) Vacating a dismissal. The appeals entity must—
(1) Vacate a dismissal and proceed with the appeal if the appellant makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated; and
(2) Provide timely written notice of the denial of a request to vacate a dismissal to the appellant, if the request is denied.
[78 FR 54136, Aug. 30, 2013, as amended at 79 FR 30349, May 27, 2014; 81 FR 12344, Mar. 8, 2016]
(a) Informal resolution. The HHS appeals process will provide an opportunity for informal resolution and a hearing in accordance with the requirements of this section. A State Exchange appeals entity may also provide an informal resolution process prior to a hearing. Any information resolution process must meet the following requirements:
(1) The process complies with the scope of review specified in paragraph (e) of this section;
(2) The appellant's right to a hearing is preserved in any case in which the appellant remains dissatisfied with the outcome of the informal resolution process;
(3) If the appeal advances to hearing, the appellant is not asked to provide duplicative information or documentation that he or she previously provided during the application or informal resolution process; and
(4) If the appeal does not advance to hearing, the informal resolution decision is final and binding.
(b) Notice of hearing. When a hearing is scheduled, the appeals entity must send written notice to the appellant and the appellant's authorized representative, if any, of the date, time, and location or format of the hearing no later than 15 days prior to the hearing date unless—
(1) The appellant requests an earlier hearing date; or
(2) A hearing date sooner than 15 days is necessary to process an expedited appeal, as described in §155.540(a), and the appeals entity has contacted the appellant to schedule a hearing on a mutually agreed upon date, time, and location or format.
(c) Conducting the hearing. All hearings under this subpart must be conducted—
(1) At a reasonable date, time, and location or format;
(2) After notice of the hearing, pursuant to paragraph (b) of this section;
(3) As an evidentiary hearing, consistent with paragraph (e) of this section; and
(4) By one or more impartial officials who have not been directly involved in the eligibility determination or any prior Exchange appeal decisions in the same matter.
(d) Procedural rights of an appellant. The appeals entity must provide the appellant with the opportunity to—
(1) Review his or her appeal record, including all documents and records to be used by the appeals entity at the hearing, at a reasonable time before the date of the hearing as well as during the hearing;
(2) Bring witnesses to testify;
(3) Establish all relevant facts and circumstances;
(4) Present an argument without undue interference; and
(5) Question or refute any testimony or evidence, including the opportunity to confront and cross-examine adverse witnesses.
(e) Information and evidence to be considered. The appeals entity must consider the information used to determine the appellant's eligibility as well as any additional relevant evidence presented during the course of the appeals process, including at the hearing.
(f) Standard of review. The appeals entity will review the appeal de novo and will consider all relevant facts and evidence adduced during the appeals process.
(1) Must issue written notice of the appeal decision to the appellant within 90 days of the date an appeal request under §155.520(b) or (c) is received, as administratively feasible.
(i) Prospectively, on the first day of the month following the date of the notice of appeal decision, or consistent with §155.330(f)(2), (3), (4), or (5), if applicable; or
(ii) Retroactively, to the coverage effective date the appellant did receive or would have received if the appellant had enrolled in coverage under the incorrect eligibility determination that is the subject of the appeal, at the option of the appellant.
(2) Redetermine the eligibility of household members who have not appealed their own eligibility determinations but whose eligibility may be affected by the appeal decision, in accordance with the standards specified in §155.305.
[78 FR 54136, Aug. 30, 2013, as amended at 81 FR 12345, Mar. 8, 2016]
(a) Appellant access to the appeal record. Subject to the requirements of all applicable Federal and State laws regarding privacy, confidentiality, disclosure, and personally identifiable information, the appeals entity must make the appeal record accessible to the appellant at a convenient place and time.
(b) Public access to the appeal decision. The appeals entity must provide public access to all appeal decisions, subject to all applicable Federal and State laws regarding privacy, confidentiality, disclosure, and personally identifiable information.
(a) General requirements. The provisions of this section apply to employer appeals processes through which an employer may, in response to a notice under §155.310(h), appeal a determination that the employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide that coverage but it is not affordable coverage with respect to an employee.
(b) Exchange employer appeals process. An Exchange may establish an employer appeals process in accordance with the requirements of this section and §§155.505(f) through (h) and 155.510(a)(1) and (2) and (c). Where an Exchange has not established an employer appeals process, HHS will provide an employer appeals process that meets the requirements of this section and §§155.505(f) through (h) and 155.510(a)(1) and (2) and (c).
(c) Appeal request. The Exchange and appeals entity, as applicable, must—
(1) Allow an employer to request an appeal within 90 days from the date the notice described under §155.310(h) is sent;
(3) Allow an employer to submit an appeal request to—
(4) Comply with the requirements of §155.520(a)(1) through (3); and
(5) Consider an appeal request valid if it is submitted in accordance with paragraph (c)(1) of this section and with the purpose of appealing the determination identified in the notice specified in §155.310(h).
(d) Notice of appeal request. (1) Upon receipt of a valid appeal request, the appeals entity must—
(ii) Send timely notice to the employee of the receipt of the appeal request, including—
(2) Upon receipt of an invalid appeal request, the appeals entity must promptly and without undue delay send written notice to the employer that the appeal request is not valid because it fails to meet the requirements of this section. The written notice must inform the employer—
(e) Transmittal and receipt of records. (1) Upon receipt of a valid appeal request under this section, or upon receipt of the notice under paragraph (d)(1)(iii) of this section, the Exchange must promptly transmit via secure electronic interface to the appeals entity—
(f) Dismissal of appeal. The appeals entity—
(1) Must dismiss an appeal under the circumstances specified in §155.530(a)(1) or if the request fails to comply with the standards in paragraph (c)(4) of this section.
(g) Procedural rights of the employer. The appeals entity must provide the employer the opportunity to—
(2) Review—
(i) The information described in §155.310(h)(1);
(iii) Other data used to make the determination described in §155.305(f) or (g), to the extent allowable by law, except the information described in paragraph (h) of this section.
(h) Confidentiality of employee information. Neither the Exchange nor the appeals entity may make available to an employer any tax return information of an employee as prohibited by section 6103 of the Code.
(i) Adjudication of employer appeals. Employer appeals must—
(j) Appeal decisions. Employer appeal decisions must—
(3) Comply with the requirements set forth in §155.545(a)(3) through (5).
(k) Notice of appeal decision. The appeals entity must provide written notice of the appeal decision within 90 days of the date the appeal request is received, as administratively feasible, to—
(1) The employer. Such notice must include—
(2) The employee. Such notice must include—
(l) Implementation of the appeal decision. After receipt of the notice under paragraph (k)(3) of this section, if the appeal decision affects the employee's eligibility, the Exchange must promptly:
(1) Redetermine the employee's eligibility and the eligibility of the employee's household members, if applicable, in accordance with the standards specified in §155.305; or
(2) Notify the employee of the requirement to report changes in eligibility as described in §155.330(b)(1).
(m) Appeal record. Subject to the requirements of §155.550 and paragraph (h) of this section, the appeal record must be accessible to the employer and to the employee in a convenient format and at a convenient time.
[78 FR 54136, Aug. 30, 2013, as amended at 79 FR 30349, May 27, 2014; 81 FR 12345, Mar. 8, 2016; 81 FR 94179, Dec. 22, 2016]