Eligibility, Coverage and Payments

Eligibility   |   Coverage   |   Payment and the Waiting List   |   Termination of Coverage   |   Impartial Eligibility Review

Impartial Eligibility Review

An impartial eligibility review may be requested when:

• An applicant is denied coverage; or
• An enrollee’s coverage is to be terminated.

(More information about non-reviewable circumstances)

A review officer will review the application/renewal documents and verification and the letter of request prior to the conference call (review interview) in order to become familiar with the case circumstances. You or your representative may submit additional documents that may have an impact on the outcome. The reviewer may ask for additional documentation as needed.

The reviewer will consider the eligibility factors, the documents provided and the relevant eligibility requirements. A written decision in the form of a letter will be prepared and sent to you and your representative (if appropriate) and, to the Caring Foundation. The Foundation will implement the decision of the review officer upon receipt of the letter.

When a request for review is received for an enrollee in adultBasic, you will be offered the option of paying the premium in order for coverage to continue pending the outcome of the review.

• If you elect to continue paying the premium, coverage will continue.
• If you elect not to pay, coverage will not continue.

Pennsylvania Insurance Department
adultBasic Eligibility Review Unit
333 Market Street, 2nd Floor Landing
Harrisburg, PA 17120
FAX: 717-705-1643

A request for an impartial review must:

• Be filed in written or printed form (e.g. letter, e-mail, FAX);
• Be post-marked or received within 30 calendar days of the date of the notice of ineligibility or termination of coverage;
• Contain the reason for the request along with a copy of the denial or termination letter from the Caring Foundation; and
• Be signed by the member.

If you request assistance in filing a written request, the Caring Foundation or Pennsylvania Insurance Department will help in whatever way is determined necessary. A sample letter for filing a request for review may be obtained by calling the Foundation at 1-800-464-5437.

NOTE: You may withdraw your request for an impartial review at any time.

• Coverage should continue or be reinstated until the review process has been concluded;
• The Insurance Department will schedule a review interview. (The review will be held by telephone unless you request a face-to-face review);
• The Foundation will be informed that the interview has been scheduled; and
• You will be informed in writing of the:
  • Date, time and location of the interview;
  • Right to have a representative during the interview;
  • Right to have appropriate interpretative service available during the interview if needed; and
  • Opportunity for continuation of coverage so long as premium payments are made.

The Caring Foundation will:

• Conduct a management review of the decision of ineligibility within two working days of the date of notification by the Insurance Department to assure that the decision made regarding ineligibility was appropriate;
• Inform the review officer of the results of the management review; and
• If the management review determines that the eligibility decision was not appropriate:
  • Inform you and the review officer in writing that an error occurred and you are eligible;
  • Enroll you retroactively to the date that you should have been enrolled; and
  • Re-enroll an enrollee who has been terminated retroactively to the date the enrollee was terminated.

NOTE: Re-enrollment of a member terminated from adultBasic is completely contingent upon the receipt of the applicable premium.

The Insurance Department will:

• Designate a review officer to conduct the eligibility review;
• Issue a written decision after the review has been completed; or
• Send confirmation that a request for a review has been withdrawn, if appropriate. Withdrawal of a request may occur if the Caring Foundation, applicant or enrollee informs the Department that the request for review has been withdrawn for any reason. Example: the Caring Foundation has resolved the matter at issue prior to the date of the scheduled review interview.

• Failure to submit a monthly payment in a timely manner;
• The applicant or enrollee is under 19 years of age or older than 64 years of age; or
• The request for a review is received more than 30 days from the date the Caring Foundation sent a notice of denial or termination.