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Is a CHC Plan Taking Away Services? Appeal!

PHLP has heard from hundreds of people across Pennsylvania over the past few months that their Community HealthChoices (CHC) plan is trying to take away or change the services that they have been getting.  Most of the calls to PHLP’s Helpline are from participants whose hours of Personal Assistance Services (PAS) or nursing services are being lowered or even taken away completely.  

When a CHC plan reduces (cuts) services, it's commonly called a service denial.  CHC Participants have a right to appeal these denials. Appealing is generally the only way to challenge the CHC plan decision and keep the services that someone has been getting in place. Appealing quickly helps the CHC Participant to keep their services during the appeal process.  

In this article, we highlight key things to know and do when a CHC plan seeks to reduce services. People can have success in appeals and do not always need legal advice or representation to win an appeal. Please see PHLP’s CHC Resources, including fact sheets on How to Appeal a Denial in CommunityHealthChoices and Proving Your Case When Personal Assistance Services Have Been Denied for more information.  

Key Things to Know When Appealing a Service Reduction 

  • File an appeal as soon as you learn about a change to services! Appealing quickly keeps your services in place during the appeal. You must appeal within 10 days of the date on the denial notice to keep your benefits during the appeal.   

  • You do not need to wait for the denial notice from the CHC plan to appeal. If you learn about a reduction from your Home Health or PAS agency, Service Coordinator, or someone from your CHC plan, you can call the member services department of your CHC plan to appeal. This phone number is on the back of your CHC plan card.  

  • If you do get a service denial letter in the mail, save that letter and the envelope. The postmark date on the envelope must be the same date as the date on the denial letter. If the dates do not match, tell your CHC plan about this difference and you may be able to keep your services even if you miss the 10-day deadline.   

  • If you file your appeal over the phone, keep a note of the day and time you call as well as the name of the person you talk to. Ask the plan for a reference number and note that as well.  If you mail or fax the appeal to the plan, try to keep a copy for your records. If you have a smart phone or other device, take a picture of the completed form.  

  • If you want someone else to file the appeal for you, you need to designate that person as a representative in writing or that person needs to have some other formal legal authority such as Power of Attorney (POA) or Legal Guardian. The plan needs copies of the POA or Guardianship papers if they are not already on file. Otherwise, the CHC plan may reject your appeal.  You can have someone with you when you call your CHC plan. You can give the CHC plan permission to talk to the other person who is with you.  

  • When you appeal, you do not need to give all the reasons you disagree with the plan’s decision. Simply say the CHC’s plan’s decision reduction or denial will not meet your needs. The plan must schedule a Grievance meeting so you can provide more information about why you disagree with the denial. You can have family members and caregivers participate in the Grievance meeting with you or for you.  

  • After you file the first appeal (also called a Grievance), you must receive a letter from the CHC plan confirming that your appeal has been filed. You will get another letter with details about the date and time of the Grievance meeting. You can ask that it be rescheduled, if needed, so that you are able to participate in the meeting.  

  • If the CHC plan continues to deny services after a Grievance meeting, there are two more appeals you can file: External Review and a Fair Hearing. You must get a letter from the CHC plan explaining their decision. This letter also has instructions about how to file the next appeal. You should keep the decision letter and the envelope it came in. Again, the date on the envelope must match the date on the Grievance Decision letter.  

  • You must file both the External Review and the Fair Hearing quickly after the Grievance to stop the services from changing or ending. Filing both appeals within 10 days of the date on the Grievance Decision letter allows the services to continue for the rest of the appeals process, even if one of these appeal options is not successful.  

  • If you only file the External Review after the Grievance, and if that External Review upholds the plan’s denial, your services will change. Even though you can still file a Fair Hearing at this point, you will not continue to get the services at the same level you had them.  

  • To file an External Review, call the CHC plan’s Member Services Department (number on back of ID card). When at all possible, keep a note about the date and time you called, the name of the person you talk to, and any reference number they give you.  

  • You must request a Fair Hearing in writing. You cannot request the Fair Hearing from your CHC plan and you cannot make the request by phone.  

  • The Fair Hearing Request Form is included in the Grievance Decision letter. This gets mailed to the Office of Long Term Living in Harrisburg, not to your CHC plan. The address where you need to mail it is on the form. If possible, you should keep copies of the completed form and mail it some way you have proof of the mail date. If you have a smart phone or other device that takes pictures, you can take a picture of the completed form as well as a postmarked or stamped envelope as proof of mailing. 

     

Case Example: 

Jack, a 76-year-old man, received a denial notice in the mail telling him that his Personal Assistance Services were dropping from 70 hours/week to 35 hours/week. As soon as Jack got this notice, he called his CHC plan to appeal. Because Jack appealed quickly (within 10 days), he kept getting 70 hours/week of help. Jack had a Grievance meeting and the CHC plan approved 50 hours/week. 

Jack was not satisfied with this decision and quickly filed an External Review. Because of this quick appeal, he continued to get the 70 hours/week while the External Review was done. The External Review came back, and it agreed with the CHC plan’s decision. Even though Jack can still pursue a Fair Hearing, his Personal Assistance Services dropped to 50 hours/week because he did not file the Fair Hearing request after the Grievance. If Jack had requested both the External Review and the Fair Hearing quickly after the Grievance decision, then Jack would continue to get 70 hours/week until he had the Fair Hearing and got a decision.  

 

People needing help navigating the appeals process or needing advice or help with their appeal can contact PHLP’s Helpline at 1-800-274-3258 or staff@phlp.org. Readers are also encouraged to see this article for other CHC resources and information.