Covered California Certified Enroller Practice Exam

What must happen if a Covered CA appeal cannot be resolved informally within 90 days?

1. CDSS will issue a denial

2. CDSS will hold a formal hearing

3. The consumer must wait for approval

4. The consumer's case is closed

The correct answer is: CDSS will hold a formal hearing

If a Covered California appeal cannot be resolved informally within 90 days, it is required that a formal hearing be held. This process is designed to ensure that the consumer has an opportunity to formally dispute the decision that has been made regarding their application or enrollment in coverage. The formal hearing allows for a more thorough examination of the case, where both parties can present evidence and arguments. The purpose of this procedure is to uphold the rights of consumers, ensuring they have a fair chance to contest decisions that affect their access to healthcare coverage. Holding a formal hearing provides a structured approach to resolving disputes, ensuring transparency and adherence to legal protocols. In this context, various alternatives do not align with the procedure. For instance, issuing a denial would not provide the consumer with the opportunity to contest the decision, while waiting for approval does not directly address the need for resolution after 90 days. Closing the case prematurely would also deny the consumer their right to appeal and potentially reach a satisfactory resolution. Thus, the necessity of a formal hearing becomes evident as a critical step in the appeals process when informal measures have not yielded a satisfactory outcome.