Problems with Home Health Care, Skilled Nursing Care, or CORF

This section is about the following types of care only:

  • Home health care services (This does not include IHSS. For IHSS problems or complaints, see the section called “Problems about Services, Items, and Drugs (Not Part D Drugs).”
  • Skilled nursing care in a skilled nursing facility.
  • Rehabilitation care you are getting as an outpatient at a Medicare-approved Comprehensive Outpatient Rehabilitation Facility (CORF). Usually, this means you are getting treatment for an illness or accident, or you are recovering from a major operation.
  • With any of these three types of care, you have the right to keep getting covered services for as long as the doctor says you need it.
  • When we decide to stop covering any of these, we must tell you before your services end. When your coverage for that care ends, we will stop paying for your care.

If you think we are ending the coverage of your care too soon, you can appeal our decision. This section tells you how to ask for an appeal.

We will tell you in advance when your coverage will be ending

The agency or facility that is providing your care will give you a notice at least two days before we stop paying for your care. The written notice tells you the date when we will stop covering your care. The written notice also tells you how to appeal this decision.You or your representative should sign the written notice to show that you got it. Signing it does not mean you agree with the plan that it is time to stop getting the care. When your coverage ends, we will stop paying.

Level 1 Appeal to continue your care

If you think we are ending the coverage of your care too soon, you can appeal our decision. Before you start, understand what you need to do and what the deadlines are. Meet the deadlines. The deadlines are important. Be sure that you understand and follow the deadlines that apply to things you must do. There are also deadlines our plan must follow. (If you think we are not meeting our deadlines, you can file a complaint.) Ask for help if you need it. If you have questions or need help at any time, please call Member Services at 1-888-522-1298 (TTY: 711). Or call your State Health Insurance Assistance Program at 1-800-824-0780 or 1-213-383-4519 (TTY: 1-213-251-7920). During a Level 1 Appeal, The Beneficiary and Family-Centered Care Quality Improvement Organization will review your appeal and decide whether to change the decision we made. You can find out how to call them by reading the Notice of Medicare Non-Coverage.

What should you ask for?

Ask them for an independent review of whether it is medically appropriate for us to end coverage for your services.

What is your deadline for contacting this organization?

You must contact the Beneficiary and Family-Centered Care Quality Improvement Organization no later than noon of the day after you got the written notice telling you when we will stop covering your care. If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization about your appeal, you can make your appeal directly to us instead.

What happens during the Beneficiary and Family-Centered Care Quality Improvement Organization's review?

The reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will ask you or your representative why you think coverage for the services should continue. You don’t have to prepare anything in writing, but you may do so if you wish. When you ask for an appeal, the plan must write a letter explaining why your services should end. The reviewers will also look at your medical records, talk with your doctor, and review information that our plan has given to them. Within one full day after reviewers have all the information they need, they will tell you their decision. You will get a letter explaining the decision.

What happens if the reviewers say Yes?

If the reviewers say Yes to your appeal, then we must keep providing your covered services for as long as they are medically necessary.

What happens if the reviewers say No?

If the reviewers say No to your appeal, then your coverage will end on the date we told you. We will stop paying our share of the costs of this care. If you decide to keep getting the home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date your coverage ends, then you will have to pay the full cost of this care yourself.

Level 2 Appeal to continue your care

If the Beneficiary and Family-Centered Care Quality Improvement Organization said No to the appeal and you choose to continue getting care after your coverage for the care has ended, you can make a Level 2 Appeal. You can ask the Beneficiary and Family-Centered Care Quality Improvement Organization to take another look at the decision they made at Level 1. If they say they agree with the Level 1 decision, you may have to pay the full cost for your home health care, skilled nursing facility care, or Comprehensive Outpatient Rehabilitation Facility (CORF) services after the date when we said your coverage would end. The Beneficiary and Family-Centered Care Quality Improvement Organization will review your appeal and decide whether to change the decision we made. You can find out how to call them by reading the Notice of Medicare Non-Coverage. Ask for the Level 2 review within 60 calendar days after the day when the Beneficiary and Family-Centered Care Quality Improvement Organization said No to your Level 1 Appeal. You can ask for this review only if you continued getting care after the date that your coverage for the care ended. Reviewers at the Beneficiary and Family-Centered Care Quality Improvement Organization will take another careful look at all of the information related to your appeal. The Beneficiary and Family-Centered Care Quality Improvement Organization will make its decision within 14 calendar days.

What happens if the review organization says Yes?

We must pay you back for our share of the costs of care you have received since the date when we said your coverage would end. We must continue providing coverage for the care for as long as it is medically necessary.

What happens if the review organization says No?

It means they agree with the decision they made on the Level 1 Appeal and will not change it. The letter you get will tell you what to do if you wish to continue with the review process. It will give you the details about how to go on to the next level of appeal, which is handled by a judge.

What if you miss the deadline for making your Level 1 Appeal?

If you miss appeal deadlines, there is another way to make Level 1 and Level 2 Appeals, called Alternate Appeals. But the first two levels of appeal are different.

Level 1 Alternate Appeal to continue your care for longer

If you miss the deadline for contacting the Beneficiary and Family-Centered Care Quality Improvement Organization, you can make an appeal to us, asking for a “fast review.” A fast review is an appeal that uses the fast deadlines instead of the standard deadlines. During this review, we take a look at all of the information about your hospital stay. We check to see if the decision about when your services should end was fair and followed all the rules. We will use the fast deadlines rather than the standard deadlines for giving you the answer to this review. We will give you our decision within 72 hours after you ask for a “fast review.” If we say Yes to your fast review, it means we agree that we will keep covering your services for as long as it is medically necessary. It also means that we agree to pay you back for our share of the costs of care you have received since the date when we said your coverage would end. If we say No to your fast review, we are saying that stopping your services was medically appropriate. Our coverage ends as of the day we said coverage would end. If you continue getting services after the day we said they would stop, you may have to pay the full cost of the services. To make sure we were following all the rules when we said No to your fast appeal, we will send your appeal to the “Independent Review Entity.” When we do this, it means that your case is automatically going to Level 2 of the appeals process.

Level 2 Alternate Appeal to continue your care for longer

We will send the information for your Level 2 Appeal to the Independent Review Entity within 24 hours of when we give you our Level 1 decision. If you think we are not meeting this deadline or other deadlines, you can make a complaint. During the Level 2 Appeal, the Independent Review Entity reviews the decision we made when we said No to your “fast review.” This organization decides whether the decision we made should be changed. The Independent Review Entity does a “fast review” of your appeal. The reviewers give you an answer within 72 hours. The Independent Review Entity is an independent organization that is hired by Medicare. This organization is not connected with our plan, and it is not a government agency. Reviewers at the Independent Review Entity will take a careful look at all of the information related to your appeal. If this organization says Yes to your appeal, then we must pay you back for our share of the costs of care. We must also continue the plan’s coverage of your services for as long as it is medically necessary. If this organization says No to your appeal, it means they agree with us that stopping coverage of services was medically appropriate. The letter you get from the Independent Review Entity will tell you what you can do if you wish to continue with the review process. It will give you the details about how to go on to a Level 3 Appeal, which is handled by a judge.

Taking your appeal beyond Level 2

Next steps for Medicare services and items

If you made a Level 1 Appeal and a Level 2 Appeal for Medicare services or items, and both your appeals have been turned down, you may have the right to additional levels of appeal. The letter you get from the Independent Review Entity will tell you what to do if you wish to continue the appeals process. Level 3 of the appeals process is an Administrative Law Judge (ALJ) hearing. If you want an ALJ to review your case, the item or medical service you are requesting will have to meet a minimum dollar amount. If the dollar value is less than the minimum level, you cannot appeal any further. If the dollar value is high enough, you can ask an ALJ to hear your appeal. If you do not agree with the ALJ’s decision, you can go to the Medicare Appeals Council. After that, you may have the right to ask a federal court to look at your appeal. If you need assistance at any stage of the appeals process, you can contact the Cal MediConnect Ombuds Program at 1-855-501-3077.

Next steps for Medi-Cal Services and Items

You also have more appeal rights if your appeal is about services or items that might be covered by Medi-Cal. If you do not agree with the State Fair Hearing decision and you want another judge to review it, you may request a rehearing and/or seek judicial review.

To request a rehearing, mail a written request (a letter) to:

The Rehearing Unit
744 P Street, MS 19-37
Sacramento, CA 95814

This letter must be sent within 30 days after you receive your decision. In your rehearing request, state the date you received your decision and why a rehearing should be granted. If you want to present additional evidence, describe the additional evidence and explain why it was not introduced before and how it would change the decision. You may contact Legal Services for assistance.
To ask for judicial review, you must file a petition in Superior Court (under Code of Civil Procedure Section 1094.5) within one year after receiving your decision. File your petition in the Superior Court for the county named in your decision. You may file this petition without asking for a rehearing. No filing fees are required. You may be entitled to reasonable attorney’s fees and costs if the Court issues a final decision in your favor. If a rehearing was heard and you do not agree with the decision from the rehearing, you may seek judicial review but you cannot request another rehearing.

For Members Affected by the Wildfires

L.A. Care wants to ensure you have access to needed health services as our state deals with the current wildfire disaster. If you have been impacted by the wildfires, please note the following:

  • Prescriptions can be refilled at an out-of-network pharmacy if medications have been lost or left behind. Call 1-888-839-9909 for further assistance.
     
  • Clinical Services can be accessed out-of-network if your usual provider is unable to work due to the wildfires. Call 1-888-522-1298 for guidance in this situation.

Medical transportation, mental health services and additional information is available at the L.A. Care website.

 

H8258_15129_2015CMC
CMS Approved
Updated 06/14/2016

 

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