Opinion ID: 4707402
Heading Depth: 3
Heading Rank: 1

Heading: Enrollee Appeal Rights

Text: Bellin first argues that she is entitled to appeal initial care hours determinations under the federal statutes and regulations governing the appeal rights of Medicaid beneficiaries. 42 U.S.C. §§ 1396a(a)(3), 1396u-2(b)(4); 42 C.F.R. Part 438. Specifically, Bellin avers that after she “enrolled with RiverSpring, RiverSpring was required to process [her] appeal of RiverSpring’s initial authorization” and to provide her notice of her right to appeal the initial determination. Appellant’s Br. 24. Bellin does not contest that she was not formally “enrolled” in RiverSpring until June 1, 2019, when her care began. Section 1396u-2 requires managed care organizations such as MLTCs to “establish an internal grievance procedure under which an enrollee who is eligible for medical assistance under the State plan under this subchapter, or a provider on behalf of such an enrollee, may challenge the denial of coverage of or payment for such assistance.” 42 U.S.C. § 1396u-2(b)(4). As explained in corresponding CMS regulations, MLTCs must provide an internal appeal right, and notice of that right, whenever the MLTC makes an “adverse benefit determination.” 42 C.F.R. § 438.404(b) (requiring that managed care organizations provide notice explaining the “adverse benefit determination,” the “enrollee’s right to request an appeal of the . . . adverse benefit determination,” and the “procedures for exercising” that right); see also id. § 438.402(c)(2)(ii) (“Following receipt of a notification of an adverse benefit determination . . . , an enrollee has 60 calendar days from the date on the adverse 31 benefit determination notice in which to file a request for an appeal to the managed care plan.”). Applicable regulations define an “adverse benefit determination” as, among other things, “[t]he denial or limited authorization of a requested service, including determinations based on the type or level of service, requirements for medical necessity, appropriateness, setting, or effectiveness of a covered benefit.” 42 C.F.R. § 438.400(b)(1). Bellin argues that RiverSpring’s initial determination that Bellin was eligible for only eight hours of personal care services per day constituted an “adverse benefit determination” within this statutory scheme. Appellant’s Br. 24. Once Bellin enrolled with RiverSpring, she maintains, RiverSpring was obliged to provide her notice of her right to appeal. We are not persuaded that the “adverse benefit determination” contemplated by these regulations includes an MLTC’s initial determination of personal care hours. An adverse benefit determination is the “denial or limited authorization of a requested service,” 42 C.F.R. § 438.400(b)(1) (emphasis added), but Bellin had no opportunity to formally “request” 24-hour, live-in personal care services when she sought an evaluation by RiverSpring. Bellin conceded before the district court that Medicaid beneficiaries do not “request” a particular number of care hours in applying for those services: she described instead an informal procedure for making “requests,” in which beneficiaries may tell an MLTC’s assessing nurse the number of care hours they hope to receive, and thereby de facto make a request for a service that may be denied or limitedly authorized. See Letter Addressed to Judge Alvin K. Hellerstein at 2, Bellin v. Zucker, 457 F. Supp. 3d 414 (S.D.N.Y. 2020) (No. 19-cv-5694 (AKH)), ECF No. 58 (explaining that the Medicaid application form “does not contain a place to request a particular number of hours of care,” but that a personal care services applicant “generally makes a request for a particular number of hours of home care services later, 32 to an MLTC nurse, who comes to the applicant’s home to determine the number of hours of home care to which the applicant is entitled”). Although Bellin argues that she “requested” 24-hour service after RiverSpring’s initial evaluation and before she enrolled and “requested” an appeal of RiverSpring’s determination after she enrolled, see Appellant’s Br. 22, 24, she does not claim that this sort of de facto informal request to an MLTC nurse is contemplated by the Medicaid laws. In Bellin’s case, after a RiverSpring nurse informed Bellin that she was going to recommend that Bellin receive eight hours of personal care services daily, Bellin alleges that she “protested” that amount of care “through her daughter,” claiming it “was woefully insufficient.” Jt. App’x 21. We do not see how this statement, or even a request made before the evaluation began, could constitute an actionable “request” for care hours that RiverSpring “denied” in its initial determination under the plain meaning of the term “request” as understood in its statutory context. In this circumstance, the statute unambiguously establishes that MLTCs’ initial personal care hours determinations cannot constitute adverse benefit determinations. This conclusion is further supported by the regulations governing notice of adverse benefit determinations. CMS regulations require that notice of decisions denying services be mailed within 14 days of the request for services. See 42 C.F.R. § 438.404(c)(3) (requiring that notice of “standard service authorization decisions that deny or limit services” be mailed to enrollees “within the timeframe specified in § 438.210(d)(1).”); id. § 438.210(d)(1) (“For standard authorization decisions, [the MLTC must] provide notice as expeditiously as the enrollee’s condition requires and within State-established timeframes that may not exceed 14 calendar days following receipt of the request for service . . . .”). Bellin maintains that pre-enrollment initial determinations of personal care services hours trigger this notice requirement based on informal requests made by potential recipients for a particular number of hours. Yet Bellin 33 concedes that only enrollees are entitled to notice under this provision. Since potential recipients have more than 14 days to accept pre-enrollment offers from MLTCs, and enrollment may not follow until weeks after that, 14 days could regularly elapse between the request for a specific number of personal care services hours and the time when a recipient enrolls in an MLTC. As a result, MLTCs could often involuntarily violate the notice provision even if they gave notice of appeal rights the day a recipient began to receive care and thus became an enrollee. Bellin responds that MLTCs could avoid this problem by “providing [each] potential enrollee with the required appeal notice when the [MLTC] makes its initial service determination.” Appellant’s Br. 27. This misunderstands the problem. While it might be feasible for MLTCs to provide the required notice to every potential enrollee at the time of the initial assessment, the regulations contemplate notice to enrollees only, and the impossibility of providing notice on the regulatory timetable, as discussed, provides another reason to doubt that Bellin’s reading of these provisions comports with their intended meaning. 24 24As the State notes, CMS knows how to require notice to potential enrollees and how to identify potential enrollees when a notice must go to them. See, e.g., 42 C.F.R. § 438.10 (requiring managed care organizations to “provide all required information in this section to enrollees and potential enrollees in a manner and format that may be easily understood and is readily accessible by such enrollees and potential enrollees”). Bellin counters that, in her view, CMS generally uses “enrollee” to include “potential enrollees” as well. Bellin’s argument relies, however, on misreadings of CMS responses to public comments published in the Federal Register. Bellin cites a CMS discussion of “potential enrollee financial liability” as if it is discussing the financial liability of potential enrollees. See Medicaid and Children's Health Insurance Program (CHIP) Programs; Medicaid Managed Care, CHIP Delivered in Managed Care, and Revisions Related to Third Party Liability, 81 Fed. Reg. 27,498, 27,507 (May 6, 2016). In fact, in the quoted passage CMS appears to be discussing the potential financial liability of enrollees, since its response is to comments recommending “that CMS revise the definition of ‘adverse benefit determination’ to include disputes regarding an enrollee’s financial liability.” 34