MNsure appeals are available for the following actions:
initial determinations and redeterminations made by MNsure of individual eligibility to purchase a qualified health plan through MNsure, made in accordance with Code of Federal Regulations, title 45, sections 155.305, (a) and (b); 155.330; and 155.335;
initial determinations and redeterminations made by MNsure of eligibility for and level of advance payment of premium tax credit, and eligibility for and level of cost sharing reductions, made in accordance with Code of Federal Regulations, title 45, sections 155.305 (f) to (g); 155.330; and 155.335;
initial determinations and redeterminations made by MNsure of employer eligibility to purchase coverage for qualified employees through the Small Business Health Options Program under Code of Federal Regulations, title 45, section 155.710 (a);
initial determinations and redeterminations made by MNsure of employee eligibility to purchase coverage through the Small Business Health Options Program under Code of Federal Regulations, title 45, section 155.710 (e);
initial determinations and redeterminations made by MNsure of individual eligibility for an exemption from the individual responsibility requirement made in accordance with Code of Federal Regulations, title 45, section 155.605;
a failure by MNsure to provide timely notice of an eligibility determination in accordance with Code of Federal Regulations, title 45, sections 155.310 (g); 155.330 (e)(1)(ii); 155.335 (h)(ii); 155.610 (i); and 155.715 (e) and (f); and
in response to a notice from MNsure under Code of Federal Regulations, title 45, section 155.310 (h), a determination by MNsure that an employer does not provide minimum essential coverage through an employer-sponsored plan or that the employer does provide coverage but is not affordable coverage with respect to an employee.
If an individual has been denied eligibility for medical assistance under Code of Federal Regulations, title 45, section 155.302 (b), an appeal of a determination of eligibility for advanced payments of the premium tax credit or cost-sharing reduction must also be treated as an appeal of medical assistance determination of eligibility.
To initiate an appeal, an appellant must file the appeal with MNsure as follows:
by Internet; or
MNsure must provide the necessary contact information for each method of filing an appeal with each written eligibility determination and also through the MNsure website.
The agency must assist any potential appellant in filing an appeal when assistance is requested.
An appeal must be received by MNsure within 90 days from the date of the notice of eligibility determination. There is a rebuttable presumption that the date of the notice of eligibility determination is five business days later than the date printed on the notice. The person may rebut this presumption by presenting evidence or testimony that they received the notice five business days after the date printed on the notice. An appeal received more than 90 days after the date of the eligibility notice will be dismissed. If the deadline for filing an appeal falls on a day that is not a business day, the filing deadline is the next business day.
Appeal request forms will be available to persons through the Internet, by in-person request, by mail, and by telephone. The following information is requested, but not required, in an appeal:
date of birth;
address, including either an e-mail address, if available, or a mailing or physical address;
MNsure programs involved in the appeal, for which a list must be provided on the appeal request form;
reason for the appeal; and
in appeals of redeterminations of eligibility, whether the appellant intends to continue at the level of eligibility and benefits before the redetermination being appealed until the appeal decision.
Appeals shall be accepted regardless of whether the requested information is provided on the form or the information is incomplete. However, failure by an appellant to provide all of the requested information may prevent resolution of the appeal or delivery of effective notice.
The date of official receipt of appeals submitted after business hours, whether filed through the Internet or by telephone, is the next business day.
The parties to an appeal have the right to the following timely notices and communications:
acknowledgement of receipt of the appeal and a scheduling order, including information regarding the appellant's eligibility pending appeal and an explanation that any advance payments of the premium tax credit paid on behalf of the tax filer pending appeal are subject to reconciliation; and
the decision and order of the MNsure board.
Any notice sent to the appellant must also be sent to the appellant's attorney or representative.
An appeals examiner shall not have ex parte contact on substantive issues with the agency, the appellant, or any person involved in an appeal. No agency employee shall review, interfere with, change, or attempt to influence the recommended decision of the appeals examiner in any appeal, except through the procedures allowed herein. The limitations in this subpart do not affect the board's authority to review or make final decisions.
Requests to reschedule a hearing must be made in person, by telephone, through the Internet, or by mail to the appeals examiner. The rescheduling request may be made orally or in writing. The requesting party must provide the other party a copy of a written request or must otherwise notify the other party of the request if the request is made orally.
Requests to reschedule a hearing with less than five calendar days' advance notice of the scheduled hearing date requires one attempt by the requesting party to contact the other party to notify them of the forthcoming request and to provide an opportunity to express disagreement, if any. Requests to reschedule a hearing with less than 24 hours' advance notice of the scheduled hearing date is at the discretion of the appeals examiner upon considering the potential prejudicial effect or burden to the appellant.
Unless a determination is formally made in writing by the appeals examiner that a request to reschedule a hearing is made for the purpose of delay or where a party has expressed disagreement, as provided for in item B, and the reason for the disagreement outweighs the need for the rescheduling, a hearing must be rescheduled by the appeals examiner for good cause as determined by the appeals examiner. Good cause includes the following:
to accommodate a witness;
to obtain necessary evidence, preparation, or representation;
to review, evaluate, and respond to new evidence;
to permit negotiations of resolution between the parties;
to permit the agency to reconsider;
to permit actions not previously taken;
to accommodate a conflict of previously scheduled appointments;
to accommodate a physical or mental illness;
where an interpreter, translator, or other service necessary to accommodate a person with a disability is needed but not available; or
any other compelling reasons beyond the control of the party that prevents attendance at the originally scheduled time.
If requested by the appeals examiner, a written statement confirming the reasons for the rescheduling request must be provided to the appeals examiner by the requesting party.
The agency, in its discretion, may offer the appellant consideration to compromise or resolve the appeal. If such an offer is made, the appellant must communicate to MNsure the appellant's acceptance or denial, including plan enrollment selection, where applicable, within 14 calendar days from the day the offer is made or the offer expires.
A hearing may be conducted by telephone, videoconference, or in person. An in-person appeals hearing will only be held at the discretion of the appeals examiner, or if the person asserts that either the person or a witness has a physical or mental disability that would impair the person's ability to fully participate in a hearing held by interactive video technology. To have the hearing conducted by videoconference or in person, a person must make a specific request for that type of hearing.
When an in-person hearing is granted, the appeals examiner shall conduct the hearing in the county where the person involved resides, unless an alternate location is mutually agreed upon before the hearing.
Where federal law or regulation does not require a telephone, videoconference, or in-person hearing and allows for a review of documentary evidence through a desk review, a telephone, videoconference, or in-person hearing will only be provided when the appeals examiner determines that such a hearing would materially assist in resolving the issues presented by the appeal.
An appellant has a right to an emergency expedited appeal when there is an immediate need for health services because a standard appeal could seriously jeopardize the appellant's life or health or ability to attain, maintain, or regain maximum function. An appellant must specify that an emergency expedited appeal is being requested when submitting the initial appeal. If an emergency develops during a pending appeal such that there has developed an immediate need for health services because a standard appeal could seriously jeopardize the appellant's life or health or ability to attain, maintain, or regain maximum function, an appellant may request an expedited appeal.
An appeals examiner must grant an emergency expedited appeal if an appellant has any of the following conditions or circumstances:
pregnancy and postpartum care;
prescriptions for chronic illnesses;
broken bones needing immediate treatment;
prescription refills necessitating physician visit;
outpatient treatment currently being received;
prescriptions for mental health conditions;
severe mood and brain disorders (e.g., schizophrenia, bipolar disorder); or
other similar conditions or circumstances.
If a request for an expedited appeal is denied, the appellant will be notified according to the process and time period required under the applicable federal law.
If a request for an expedited appeal is accepted, the appeals examiner will issue a decision according to the process and time period required under the applicable federal law.
Appeals must be accessible to appellants who have limited English proficiency, appellants who require interpreter and translation services, and appellants with disabilities. An appeals examiner has a duty to inquire whether any person involved in the hearing needs the services of an interpreter, translator, or reasonable accommodations to accommodate a disability in order to participate in or to understand the appeal process.
Necessary interpreter services, translation services, or reasonable accommodations must be provided at no cost to the person involved in the appeal.
If an appellant requests interpreter services, translation services, or reasonable accommodations or it appears to the appeals examiner that necessary interpreter or translation services are needed but not available for the scheduled hearing, the hearing shall be rescheduled to the next available date when the appropriate services can be provided.
Subject to the requirements of all applicable state and federal laws regarding privacy, confidentiality, and disclosure of personally identifiable information, the appellants and agencies involved in an appeals hearing must be allowed to access the appeal record upon request at a convenient place and time before and during the appeals hearing. Upon request, copies of the appeal record, including an electronic copy of the recorded hearing, must be provided at no cost and, upon request, must be mailed or sent by electronic transmission to the party or the party's representative.
An appellant involved in an appeals hearing may enforce the right of access to data and copies of the case file by making a request to the appeals examiner. The appeals examiner shall make an appropriate order enforcing the appellant's right of access, including but not limited to ordering access to files, data, and documents possessed by the agency; continuing or rescheduling an appeal hearing to allow adequate time for access to data; or prohibiting use by the agency of files, data, or documents that have been generated, collected, stored, or disseminated in violation of the requirements of state or federal law, or when the documents have not been provided to the appellant involved in the appeal.
Data on individuals, as defined in Minnesota Statutes, section 13.02, subdivision 5, will be collected about persons and appellants throughout the appeals process. The purpose of this data collection is to conduct an appeal. A party to an appeal is not required to supply data for an appeal. However, deciding which evidence and testimony to submit may have an impact on the outcome of the appeal decision. Certain other government officials may have access to information provided throughout the appeals process if this is allowed by law or pursuant to a valid court order.
When an appeal proceeds beyond the MNsure appeals process to judicial review, the appeal record will be public unless the court with jurisdiction over the appeal issues a protective order. When the appeal proceeds outside of the MNsure appeals process to the United States Department of Health and Human Services, the record will be classified according to federal law governing the collection of data on individuals.
The agency must prepare an appeal summary for each appeal hearing. The appeal summary shall be delivered to each party and the MNsure appeals examiner at least three business days before the date of the appeal hearing. The appeals examiner shall confirm that the appeal summary is delivered to the party involved in the appeal as required under this subpart. Each party shall be provided, through the appeal summary or other reasonable methods, appropriate information about the procedures for the appeal hearing and an adequate opportunity to prepare. The contents of the appeal summary must be adequate to inform each party of the evidence on which the agency relies and the legal basis for the agency's action or determination.
An appellant may personally appear in any appeal hearing and may be represented by an attorney or representative. A partnership may be represented by any of its members, an attorney, or other representative. A corporation or association may be represented by an officer, an attorney, or other representative. In a case involving an unrepresented appellant, the appeals examiner shall examine witnesses and receive exhibits for the purpose of identifying and developing in the appeal record relevant facts necessary for making an informed and fair decision. An unrepresented appellant shall be provided an adequate opportunity to respond to testimony or other evidence presented by the agency at the appeal hearing. The appeals examiner shall ensure that an unrepresented appellant has a full and reasonable opportunity at the appeal hearing to establish a record for appeal. An agency may be represented by an employee or an attorney, including an attorney employed by the agency as authorized by law.
The appeals examiner must dismiss an appeal if the appellant:
withdraws the appeal orally or in writing;
fails to appear at a scheduled appeal hearing or prehearing conference and good cause is not shown;
fails to submit a valid appeal; or
dies while the appeal is pending.
If an appeal is dismissed, the appeals examiner must provide timely notice to the parties, which must include the reason for dismissal, an explanation of the dismissal's effect on the appellant's eligibility, and an explanation of how the appellant may show good cause why the dismissal should be vacated.
The appeals examiner must vacate a dismissal if the appellant makes a written request within 30 days of the date of the notice of dismissal showing good cause why the dismissal should be vacated. There is a rebuttable presumption that the date of the notice of dismissal is five business days later than the date printed on the notice. The person may rebut this presumption by presenting evidence or testimony that they received the notice later than five business days after the date printed on the notice. Good cause can be shown when there is:
a death or serious illness in the person's family;
a personal injury or physical or mental illness that reasonably prevents an appellant or witness from attending the hearing;
an emergency, crisis, including a mental health crisis, or unforeseen event that reasonably prevents an appellant or witness from attending the hearing;
an obligation or responsibility of an appellant or witness which a reasonable person, in the conduct of one's affairs, could reasonably determine takes precedence over attending the hearing;
lack of or failure to receive timely notice of the hearing in the preferred language of an appellant involved in the hearing;
excusable neglect, excusable inadvertence, or excusable mistake as determined by the appeals examiner; or
any other compelling reason beyond the control of the party as determined by the appeals examiner.
The appeals examiner, at the examiner's discretion, prior to an appeal hearing may hold a prehearing conference to further the interests of justice or efficiency. The parties must participate in any prehearing conference held. A party may request a prehearing conference. The prehearing conference may be conducted by telephone, in writing, or in person. The prehearing conference may address the following issues:
disputes regarding access to files, evidence, subpoenas, or testimony;
the time required for the hearing or any need for expedited procedures or decision;
identification or clarification of legal or other issues that may arise at the hearing;
identification of and possible agreement to factual issues; and
scheduling and any other matter that will aid in the proper and fair functioning of the hearing.
The chief appeals examiner shall remove an appeals examiner from any case where the appeals examiner believes that presiding over the case would create the appearance of unfairness or impropriety. No appeals examiner may hear any case where any of the parties to the appeal are related to the appeals examiner by blood or marriage. An appeals examiner must not hear any case if the appeals examiner has a financial or personal interest in the outcome. An appeals examiner having knowledge of such a relationship or interest must immediately notify the chief appeals examiner and be removed from the case.
A party may move for the removal of an appeals examiner by written application of the party together with a statement of the basis for removal. Upon the motion of the party, the chief appeals examiner must decide whether the appeals examiner may hear the particular case. Removal of an appeals examiner under this item is at the discretion of the chief appeals examiner.
In appeals involving a redetermination of an appellant's eligibility, the appellant shall continue at the level of eligibility and benefits before the redetermination being appealed only if the appellant affirmatively elects to receive them during the appeal.
The appeal type, as specified in subpart 1, item A, determines what eligibility and benefits are available to be continued pending appeal. The availability of a continuation of eligibility and benefits is only available for appellants under subpart 1, item A, subitems (1) and (2). If appealing eligibility for advanced payments of premium tax credits and/or cost-sharing reductions, at issue is the amount of the advance payments of premium tax credits and/or cost-sharing reductions; and if appealing the eligibility to purchase a QHP through MNsure, at issue is the eligibility to purchase a QHP through MNsure.
Where an appellant continues at the level of eligibility before the redetermination being appealed and the appeal decision upholds the redetermination being appealed, the appellant is subject to reconciliation and repayment of any overpayment.
The appeals examiner shall begin each hearing by describing the process to be followed in the hearing, including the swearing in of witnesses, how testimony and evidence are presented, the order of examining and cross-examining witnesses, and the opportunity for an opening statement and a closing statement. The appeals examiner shall identify for the parties the issues to be addressed at the hearing and shall explain to the parties the burden of proof that applies to the appellant and the agency. The appeals examiner shall confirm, prior to proceeding with the hearing, that the appeal summary, if prepared, has been properly completed and provided to the parties, and that the parties have been provided documents and an opportunity to review the appeal record, as provided in this part.
The appeals examiner shall act in a fair and impartial manner at all times. At the beginning of the appeal hearing, the agency must designate one person as a representative who shall be responsible for presenting the agency's evidence and questioning any witnesses. The appeals examiner shall make sure that both the agency and the appellant are provided sufficient time to present testimony and evidence, to confront and cross-examine all adverse witnesses, and to make any relevant statement at the hearing. All testimony in the hearing will be taken under oath or affirmation. The appeals examiner shall make reasonable efforts to explain the appeal hearing process to unrepresented appellants and shall ensure that the hearing is conducted fairly and efficiently. Upon the reasonable request of the appellant or the agency or at the discretion of the appeals examiner, the appeals examiner shall direct witnesses to remain outside the hearing room, except during individual testimony, when the appeals examiner determines that such action is appropriate to ensure a fair and impartial hearing. The appeals examiner shall not terminate the hearing before affording the appellant and the agency a complete opportunity to submit all admissible evidence and reasonable opportunity for oral or written statement. In the event that an appeal hearing extends beyond the time allotted, the appeal hearing shall be continued from day to day until completion. Appeal hearings that have been continued shall be timely scheduled to minimize delay in the disposition of the appeal.
The appeal hearing shall be a de novo review and shall address the correctness and legality of the agency's action and shall not be limited simply to a review of the propriety of the agency's action. The appellant may raise and present evidence on all legal claims or defenses arising under state or federal law as a basis for the appeal, excluding any constitutional claims that are beyond the jurisdiction of the appeal hearing. The appeals examiner may take official notice of adjudicative facts.
The burden of persuasion is governed by specific state or federal law and regulations that apply to the subject of the hearing. Unless otherwise required by specific state or federal laws that apply to the subject of the appeal, the appellant carries the burden to persuade the appeals examiner that a claim is true and must demonstrate such by a preponderance of the evidence.
The appeals examiner shall accept all evidence, except evidence privileged by law, that is commonly accepted by reasonable people in the conduct of their affairs as having probative value on the issues to be addressed at the appeal hearing. The appeals examiner shall ensure for all cases that the appeal record is sufficiently complete to make a fair and accurate decision.
The agency must present its evidence prior to or at the appeal hearing. The parties shall not be permitted to submit evidence after the hearing except:
by agreement at the hearing between the appellant, the agency, and the appeals examiner;
in response to new evidence; or
when determined necessary by the appeals examiner to receive evidence needed to sufficiently complete the appeal record and make a fair and accurate decision.
If a party submits evidence after the appeal hearing, the other party must be allowed sufficient opportunity to respond to the evidence.
A timely, written decision must be issued in every appeal. Each decision must contain a clear ruling on the issues presented in the appeal hearing and contain a ruling only on questions directly presented by the appeal and the arguments raised in the appeal.
A written decision must be issued within 90 days of the date the appeal is received, as administratively feasible, unless a shorter time is required by law.
The decision must contain both findings of fact and conclusions of law, clearly separated and identified. The findings of fact must be based on the entire appeal record. Each finding of fact made by the appeals examiner shall be supported by a preponderance of the evidence unless a different standard is required by law. The legal claims or arguments of a participant do not constitute either a finding of fact or a conclusion of law, except to the extent the appeals examiner explicitly adopts an argument as a finding of fact or conclusion of law.
The decision shall contain at least the following:
a listing of the date and place of the appeal hearing and the parties and persons appearing at the appeal hearing;
a clear and precise statement of the issues, including the dispute that is the subject of the appeal and the specific points that must be resolved in order to decide the case;
a listing of each of the materials constituting the appeal record that were placed into evidence at the appeal hearing, and upon which the appeal hearing decision is based;
the findings of fact based upon the entire appeal record. The findings of fact must be adequate to inform the parties and the public of the basis of the decision. If the evidence is in conflict on an issue that must be resolved, the findings of fact must state the reasoning used in resolving the conflict;
conclusions of law that address the legal authority for the appeal hearing and the ruling, and which give appropriate attention to the claims of the parties;
a clear and precise statement of the decision made resolving the dispute that is the subject of the appeal, including the effective date of the decision; and
written notice of any existing right to appeal, including taking an appeal to the United States Department of Health and Human Services and identifying the time frame for an appeal and that the decision is final unless appealed.
The appeals examiner shall not independently investigate facts or otherwise rely on information not presented at the appeal hearing. However, if the appeals examiner needs further clarification from the parties, the appeals examiner may request clarification from the parties at any time until a decision is issued. The appeals examiner may not contact other agency personnel, except as provided in subpart 16. The appeals examiner's recommended decision must be based exclusively on the testimony and evidence made part of the appeals record, legal arguments presented, and the appeals examiner's research and knowledge of the law.
The MNsure board shall review the recommended decision and accept or refuse to accept the decision. The MNsure board may accept the recommended order of an appeals examiner and issue the order to the parties or may refuse to accept the decision. Upon refusal, the MNsure board shall notify the parties of the refusal, state the reasons, and allow each party ten days to submit additional written argument on the matter. After the expiration of the ten-day period, the MNsure board shall issue an order on the matter to the parties. Refusal of the MNsure board to accept a decision must not delay the 90-day time limit to issue a decision.
Orders of the MNsure board shall be implemented either:
prospectively on the first day of the month following the notice of appeal decision; or
retroactively to the date ordered by the appeals examiner, at the option of the appellant.
An appellant shall communicate to the agency the appellant's plan enrollment selection within 60 calendar days from the notice of the appeal decision or the enrollment opportunity expires.
Appeal decisions must be maintained in a manner so that the public has ready access to previous decisions on particular topics, subject to appropriate procedures for compliance with applicable state and federal laws regarding the privacy, confidentiality, and disclosure, of personally identifiable information. Appeal hearings conducted under this part are not open to the public due to the not public classification of the information provided for inclusion in the appeal record.
A party aggrieved by an order of the MNsure board may appeal under subpart 19 or 20, as applicable, or request reconsideration by the MNsure board within 30 days after the date the MNsure board issues the order. The MNsure board may reconsider an order upon request of any party or on the MNsure board's own motion. A request for reconsideration does not stay implementation of the MNsure board's order. The party seeking reconsideration has the burden to demonstrate why the matter should be reconsidered. The request for reconsideration may include legal argument and proposed additional evidence supporting the request, but this information is not required. If proposed additional evidence is submitted, the party must explain why the proposed additional evidence was not provided at the time of the hearing. If reconsideration is granted, the other parties must be sent a copy of all material submitted in support of the request for reconsideration and must be given ten days to respond. Upon reconsideration, the MNsure board may issue an amended order or an order affirming the original order.
Any order of the MNsure board issued under this subpart shall be final upon the parties unless an appeal is made in the manner provided under subpart 19 or 20, as applicable. Any order of the MNsure board is binding on the parties and must be implemented until the order is reversed.
A vendor, contractor, health insurance carrier, or other MNsure stakeholder is not a party and may not request a hearing or seek judicial review of an order issued under this part unless the vendor, contractor, health insurance carrier, or other MNsure stakeholder is assisting an appellant as a representative.
Administrative review by the United States Department of Health and Human Services may be available for parties aggrieved by an order of the MNsure board.
An appeal under this part must be filed with the United States Department of Health and Human Services and MNsure within 30 days of the date of the appeal decision according to the process required under the applicable federal regulations.
38 SR 397; 40 SR 1602
September 10, 2018