How do I file a Covered CA or Medi-Cal Appeal?

Reasons for filing a Covered CA appeal

Your eligibility notice explains what you are eligible for and the programs for which you do not qualify. Depending on your eligibility results, you may appeal any of the following (check as many boxes as you would like):

 I was denied enrollment into a Covered California health plan
 The amount of Premium Assistance (tax credits that help pay my monthly premium) is not correct – Get Calculation
 The level of Cost Sharing Reduction (help paying my out of pocket expenses) is not correct
 I was denied eligibility for an exemption from the individual responsibility CA Mandate Penalty
 Covered California did not process my information in a timely manner
 Covered California stated that I am not a US Citizen or US National or a lawfully present individual living in the United States
 Covered California stated that my application was incomplete
 I do not have other health coverage (such as free Medi-Cal or employer sponsored insurance) that prevents me from qualifying for insurance through Covered California
 Covered California stated that I am not a California Resident
 Covered California stated that I did not pay my premiums by my due date
 Covered California stated that my MAGI income is too low chart to qualify for Covered California coverage  Get Calculation
Other Tell us more about why you disagree with Covered California’s decision. You may attach additional sheets of paper if you need more space to write.  Covered CA Appeals Request Form

 

We STRONGLY suggest you attach additional sheets of paper and explain your case, with citations, evidence & exhibits.   Be sure to read all the helpful aids we have on this page.  You are going up against well versed opponents!

We are not attorneys and can just point out the law, rules, relevant sections in the EOC Evidence of Coverage.

Check out the forms and Appeals Procedure on Covered CA’s Website , the materials below and to the right, our main page on Appeal & Grievances?  and the child & sibling pages.

We also need you to write out your story and including all the proofs – evidence & exhibits.

See also our main page on appeals, namely how to gather your evidence and exhibits.   Here’s an example of a decision from the Administrative Law Judge for Covered CA.

We might be able to help you file and process your  appeal  (click for form)  , IF you appoint us (Steve Shorr) as your Certified Insurance Agent, by  following these instructions as we are paid a measly monthly sum  by Covered CA to help you.

Medi-Cal Appeal & Hearing Rights

Health Care Services and Benefits

You have the right to ask for an appeal if you disagree with the denial of a health care service or benefit.

If you are in a Medi-Cal managed care plan and you get a Notice of Action letter telling you that a health care service or benefit is denied, you have the right to ask for an appeal.

You must file an appeal with your plan within 60 days of the date on the Notice of Action. After you file your appeal, the plan will send you a decision within 30 days. If you do not get a decision within 30 days or are not happy with the plan’s decision, you can then ask for a State Fair Hearing. A judge will review your case.  You must first file an appeal with your plan before you can ask for a State Fair Hearing. You must ask for a State Fair Hearing within 120 days of the date of the plan’s written appeal decision.

If you are in Fee-for-Service Medi-Cal and you get a Notice of Action letter telling you that a health service or benefit has been denied, you have the right to ask for a State Fair Hearing right away. You must ask for a State Fair Hearing within 90 days of the date on the Notice of Action.

You also have the right to ask for a State Fair Hearing if you disagree with what is happening with your Medi-Cal application or eligibility. This can be when:

• You do not agree with a county or State action on your Medi-Cal application
• The county does not give you a decision about your Medi-Cal application within 45 or 90 days
• Your Medi-Cal eligibility or Share of Cost changes Eligibility Decisions

If you get a Notice of Action letter telling you about an eligibility decision that you disagree with, you can talk to your county eligibility worker and/or ask for a State Fair Hearing. If you cannot solve your disagreement through the county, you must request a State Fair
Hearing within 90 days of the date on the Notice of Action. You can ask for a State Fair Hearing by contacting your local county office. You can also call or write to:

California Department of Social Services
Public Inquiry and Response
PO Box 944243, M.S. 9-17-37
Sacramento, CA 94244-2430
1-800-743-8525, (TTY 1-800-952-8349)

You can also file a hearing request online at:

https://www.cdss.ca.gov/hearing-requests 

If you believe you have been unlawfully discriminated against on the basis of sex, race, color, religion, ancestry, national origin, ethnic group identification, age, mental disability, physical disability, medical condition, genetic information, marital status, gender, gender identity, or sexual orientation, you can make a complaint to the DHCS Office of Civil Rights.

You can learn how to make a discrimination complaint in “Federally Required Notice Informing Individuals About Nondiscrimination and Accessibility Requirements” on page 21.

About State Fair Hearings

The State will tell you it got your hearing request. You will get a notice of the time, date and place of your hearing. A hearing representative will review your case and try to resolve your issue. If the county/State offers you an agreement to solve your issue, you will get it in writing.

You can give permission in writing for a friend, family member or advocate to help you at the hearing. If you cannot fully solve your issue with the county or State, you or your representative must attend the State Fair Hearing. Your hearing can be in person or by phone. A judge who does not work for the county or Medi-Cal program will hear your case.

You have the right to free language help. List your language on your hearing request. Or tell the hearing representative you would like a free interpreter. You cannot use family or friends to interpret for you at the hearing.

If you have a disability and need reasonable accommodations to fully take part in the Fair Hearing process, you may call 1-800-743-8525 (TTY 1-800-952-8349).

You can also send an email to To get help with your hearing, you can ask for a legal aid referral. You may get free legal help at your local
legal aid or welfare rights office MyMedi-Cal Pamphlet *

 

See also our webpage on appeals & grievances,  Medicare Appeals & grievances.

Covered CA Appeals Decision

Covered CA Appeals Decision

Sample Letter for Appeal

Sample Letter for Covered CA Appeal

 

Explanation on Insure Me Kevin . com   Polk Case

Appeal Guide 
DOI Washington State

how to appeal health care insurance decesion

*************************

Navigating the Appeals Process -

Patient Advocate Foundation 

Navigating the Appeals Process

 

Kantor & Kantor Attorneys

Right to Appeal - if claim denied

You Tube Videos

 

CA Small Claims Court Guide 56 Pages
Gathering the documents you need
CA Small Claims Court Guide

courts.ca.gov/selfhelp-smallclaims

Small Claims Court Procedures & Practices – including training for judges

California Small Claims – Court Site – Self Help

Fillable Forms

Department of Consumer Affairs on Small Claims Court

♦  Legal Aid Society of Orange County, CA

Small Claims Adviser Los Angeles 213.974.9759

Department of Consumer Affairs - Mediation Request ONLINE

mediation request

How Mediation Works & Paper Mediation Request Form

 

Small Claim Court Study Guide for temporary – pro tem judges – highly likely you might have an attorney whose volunteering to be a Judge for the day.

If you have a claim for more than the Small Claims Limit, you can sue, but you waive the amount over the limit.

Appeals?  Grievances?

Check the FULL policy, EOC - Evidence of Coverage here's a specimen and see what the rules are on cancellation and notice.

Then if you do decide to do an appeal, (page 151 in specimen policy) or view our webpage  on appeals, you'll  know what to argue about.

FAQ's + You can ask a question

FAQ’s – Ask us a Question

Historical

Their service is the worst I have seen since earning my Degree in Insurance at San Diego State University in 1975.  I learned the word SNAFU from a guy I knew in the Dorm.  This is the first time, I’ve been able to use the word in “real” life.   Please note how many of the 8,000 certified agents are now refusing to deal with Covered CA.  See screen shots below from Ehealth Insurance and another agent.  It’s twice the work, for less than 1/2 of what we were paid last year and “criminal” support and customer service!

However, if you qualify for Medi-Cal we do not get compensated and it appears we are supposed to refer you to your local County Medi Cal Agency.

Hurry, we may well soon be FORCED to charge a fee for appeals and consultation for Covered CA.

1.29.2015 Update – Through the Covered CA Agent Portal & Email, I’m now getting pretty good service & response.

fluker
One of our friendly competitors is leaving the market

 ehealht

Appeals Law

Subpart F—Appeals of Eligibility Determinations for Exchange Participation and Insurance Affordability Programs

§155.500   Definitions.

§155.505   General eligibility appeals requirements.

§155.510   Appeals coordination.

§155.515   Notice of appeal procedures.

§155.520   Appeal requests.

§155.525   Eligibility pending appeal.

§155.530   Dismissals.

§155.535   Informal resolution and hearing requirements.

§155.540   Expedited appeals.

§155.545   Appeal decisions.

§155.550   Appeal record.

§155.555   Employer appeals process.

July 23, 2010 OCIIO-9993-IFC: Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Internal Claims and Appeals and External Review Processes Under the Patient Protection and Affordable Care Act – Opens in a new window (PDF – 257 KB)

CA CCR

Article 7. Appeals Process for the Individual Exchange

8 comments on “Covered CA Appeals

  1. I made a mistake and took my child off the coverage as she was out of state to go to college. She’s in the ER, what can I do?

Leave a Reply

Your email address will not be published.