It is my understanding that some tiers letter still have not been received.  Much of this information is from Aaron Nangle of WaiverProvider.com. If you believe that the tier you have been placed in will not meet your needs, you can appeal.  But there is a process.

        It is very important to send a letter of appeal within 10 days of the time you receive your tier assignment.  In this way, you will be able to keep the services you currently have.

        If you appeal within 10 days and you desire to keep your services, you are advised to keep the original envelop that your tier assignment came in.  In this way, you can prove the date that you received your letter.  If you don’t apply within 10 days, you can still appeal your tier assignment withn 30 days but you will not be able to continue with your current services.

        If you are appealing your tier assignment, do not sign a new cost plan.  This will be a contract.  If you sign it, you are saying that you agree with the cost plan you are presented with.  This could and probably will void your appeal.

        Understand that it will be easy for you to move down a tier but hard to move up. 

        Personal Care Attendants (PCA) may not be included in your Waiver funding.  However, if you are under the age of 21, this service is available to you through Medicaid funding.  If you have been excluded from this service because of the tier you are in and you are under 21, try to receive this service through a different funding stream.

         Because the tiers are mandated by the legislature, not APD, the appeal process is somewhat different from other appeals.  They are also more difficult to win.  Your appeal must be written from the point of view that the services you will receive in your new plan will not meet your health and safety needs. 

Below and in quotes is a comment I received yesterday regarding the sample appeal letter I published in this weblog.  I don’t know the person who wrote this.  He didn’t include his name and I know nothing about him.  However, the information did seem credible so I’ve included it.  He is concerned about the federal implications of the appeals. 

In an effort to obtain more information, I e-mailed a congressional office in Florida.  This was the reply I received. 

State regulations have always trumped federal action for other Medicaid issues, so I don’t think this information is correct.  The federal system won’t hold hearings, they are done at the state level.  When we send these issues to a federal liaison, they ALWAYS buck it to the state administrated agency.
 
I can’t say this is true for this issue, but I would venture to say the federal government WILL DO NOTHING.
For your information and consideration, here is the e-mail I received.
It appears to me that this form was developed by the Advocacy Center for Persons with Disabilities based on its “If they don’t play fair, level the playing field” manual to adminstrative hearings. While it is laudable that the Center put together an assistance aid for pro se hearing participants, the Manual does not appear to take into consideration the federal law “fair hearing” requirements governing “fair hearings” mandated by Title IXX of the Social Security Act.
 
Instead, its recommendations apparently are based exclusively on the Administrative Procedures Act, Chapter 120, Florida Statutes, which requires a hearing when a person’s “substantial interests” are affected. The “substantial interests” test of Chapter 120 is not an issue in federally guaranteed fair hearings on Medicaid services.
 
Based on the doctrine of Federal Supremacy, Federal law trumps state law, including Chapter 120, the Administrative Procedures Act. Anyone wishing to challenge agency action under a Medicaid program should understand that the Federal Fair Hearing regulations of the Code of Federal Regulations require that the Medicaid agency provide a hearing ONLY when services are denied, suspended, terminated, or reduced. Moreover, the federal rules allow an agency to deny a hearing for across-the-board changes in law. This would seem to include the implementation of the tier waivers.
 
From that perspective, and because assignment to a particular tier waiver is an agency administrative action rather than a direct action on services, a petitioner for hearing must be very careful to couch any request for hearing in the context of services actually, rather than possibly or prospectively, affected by the assignment: the agency must have acted to impose a denial, reduction, suspension, or termination of services.
 
In sum, federal law provides hearings based on services as opposed to tier waiver assignments. You would be well advised to couch your hearing assignments on actual actions against your service requests rather than the tier assignment.