Current through September 18, 2024
Authority: IC 12-15-44.5-9
Affected: IC 12-15-44.5
Sec. 3.
(a) This
subsection applies to an aggrieved member requesting an administrative appeal
under section 1 or 2 of this rule as follows:
(1) If an aggrieved member requests an
administrative hearing as provided in the notice of adverse action, prior to
the effective date of the adverse action, plan coverage shall continue without
change until an administrative law judge issues a decision after the hearing
under
405 IAC 1.1-1-6.
If POWER account contributions were required for that member to receive
services, the member shall continue to make contributions to the member's POWER
account during the appeal in order to continue coverage.
(2) If the administrative law judge sustains
the action, the member shall be responsible for repaying the cost of any
services furnished by reason of this section, minus any POWER account
contributions made for coverage during the pendency of the appeal.
(3) If the action under appeal is overturned,
the state or the managed care organization shall make coverage available
effective to the date the overturned action was taken. However, unless the
member is not required to make POWER account payments to maintain coverage, the
individual shall make any POWER account payments that became due during the
appeal within sixty (60) days of the managed care organization's date of
invoice in order to continue participating in the plan.
(4) A member shall not receive continued
benefits pending the outcome of an administrative hearing if:
(A) the action is the result of the member's
nonpayment of POWER account contributions; or
(B) the member requests in writing that plan
benefits not be maintained pending the administrative appeal.
(b) This subsection
applies to an applicant requesting an administrative appeal under section 1 or
2 of this rule. If an applicant was determined ineligible but receives a
favorable decision on appeal, coverage begins as follows:
(1) For an applicant who made either a fast
track prepayment as provided under
405 IAC 10-3-3(c)
or initial POWER account contribution, the
first day of the month in which the individual made either the fast track
prepayment or the initial POWER account contribution.
(2) For an applicant who made neither a fast
track prepayment nor an initial POWER account contribution prior to the date of
the appealable action, such individual shall be given a period of time to make
either a fast track prepayment or an initial POWER account contribution. This
period of time shall be equal to the amount of time remaining in the
applicant's payment period from the date of the office's erroneous action. Such
period begins on the date of the managed care organization's new invoice issued
after the favorable decision on appeal. If the individual makes either a fast
track prepayment or POWER account contribution within this period, the
individual shall receive a coverage start date intended to put such individual
in the position the applicant would have been in but for the office's erroneous
determination.
(c) An
aggrieved applicant requesting an administrative appeal under section 1 or 2 of
this rule who receives a favorable determination and is enrolled in either HIP
Plus or HIP State Plan Plus in accordance with subsection (b) shall make the
required POWER account contributions that accrued during the appeal within
sixty (60) days of the date of the invoice in order to continue to be eligible
to receive HIP Plus or HIP State Plan Plus coverage. An individual who does not
make the required contributions within sixty (60) days of the date of invoice
shall:
(1) be transferred to HIP Basic or HIP
State Plan Basic if the individual is at or below one hundred percent (100%) of
the FPL; or
(2) become ineligible
for participation in the plan if such individual is above one hundred percent
(100%) of the FPL.
