Www.medicareadvocacy.org Copyright © Center for Medicare Advocacy, Inc. MEDICARE APPEALS Families...

www.medicareadvocacy.orgCopyright © Center for Medicare Advocacy, Inc.

MEDICARE APPEALS

Families USA ConferenceJanuary 26, 2007

Vicki GottlichCenter for Medicare Advocacy

Heather BatesHealth Assistance Partnership

Kelly BrantleyHealth Assistance Partnership

______________

www.medicareadvocacy.org


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A REVIEW

Medicare Part A• Hospital, SNF, some home health, hospice

Medicare Part B• Doctors’ visits, DME, some home health

Medicare Part C• A delivery mechanism for Parts A & B benefits

Medicare Part D• Prescription drugs


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EXPEDITED APPEALS PROCESS – MEDICARE PARTS A & B

Expedited process provides appeal before services end if • Discharge from skilled nursing facility, hospice

services or

• Termination from home health services or CORF • For home health and CORF doctor must certify that failure to

continue services is likely to place health at risk or all Medicare covered services

• Not available if services only being reduced

• Similar process for hospital discharge


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EXPEDITED APPEALS PROCESS – MEDICARE PARTS A & B

Beneficiary not liable until later of 2 days after date of notice or termination date

www.cms.hhs.gov/BNI/01_overview.asp#TopOfPage (describes expedited determination (“ED”) and other notice requirements)

http://www.cms.hhs.gov/BNI/01_overview.asp#TopOfPage

http://www.cms.hhs.gov/BNI/01_overview.asp#TopOfPage


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EXPEDITED APPEALS PROCESS (cont.)

Provider must give beneficiary general, standardized notice 2 days in advance.

Beneficiary must request expedited review by QIO by noon of next calendar day after receiving notice.

Provider must give beneficiary more specific notice by end of day beneficiary requests expedited review if such review is requested.


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EXPEDITED APPEALS PROCESS (cont.)

QIO reviews expedited appeal request • Gets information from provider by close of business the

day QIO receives the appeal

• Solicits views of beneficiary

• 72 hrs to issue decision

Beneficiary may request expedited reconsideration of QIO decision by noon of day following decision

QIO has 72 hrs to act on reconsideration request


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PART A & PART B PROCESS (Non-Expedited)

Beneficiary receives the service Medicare contractor (fiscal intermediary or carrier)

issues initial determination explaining whether Medicare will pay for a service already received.

Beneficiary has 120 days to request redetermination by contractor. Provider may also request redetermination• Appeals will be consolidated• Time frame may be extended for “good cause”

Contractor has 60 days to issue redetermination


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PART A & PART B APPEALS (cont.)

If redetermination is unfavorable can request a“reconsideration” by Qualified Independent

Contractors (QICs) • 120 days to request reconsideration • Beneficiary & provider appeals will be consolidated • Time may be extended for good cause

QIC must issue decision within 60 days. • Parties may request escalation to ALJ if time frame not

met 60 days to request review by ALJ


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ALJ HEARINGS

Hearings conducted by Medicare ALJs in DHHS Office of Medicare Hearings and Appeals

ALJs are in 4 regional offices, not local offices• Cleveland, OH• Irvine, CA• Miami, FL• Arlington, VA

For Part A and Part B claims, ALJ must issue decision within 90 days – with exceptions • No time limit if request for in-person hearing granted


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ALJ HEARINGS (cont.)

For ALJ hearings under Parts A, B, C & D Amount of claim must be at least $110 in 2007

• Subject to annual increase

• Can aggregate certain claims

Hearings conducted by video teleconferencing (VTC) if available, or by telephone • ALJ assigned to case has discretion to grant request for

in-person hearing


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APPEALS PROCESS – BEYOND THE ALJ HEARING

If ALJ decision is unfavorable, have 60 days to request MAC review• MAC request requires specific statement of issues,

• MAC reviews the record concerning only those issues, unless unrepresented beneficiary requests.

If MAC decision is unfavorable, have 60 days to request review in federal court• Must meet amount in controversy requirement

• Amount may increase each year ($1130 in 2007)


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CALCULATING TIME FRAMES

Time frames are generally calculated from date of receipt of notice

5 days added to notice date Time frames sometimes extended for good cause,

ex.• Serious illness• Death in family• Records destroyed by fire/flood, etc• Did not receive notice• Wrong information from contractor• Sent request in good faith but it did not arrive


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MEDICARE ADVANTAGE APPEALS

“Organization determination” is initial determination regarding basic and optional benefits• Can be provided before or after services received

• Issued within 14 days

May request expedited organization determination if delay could jeopardize life/health or ability to regain maximum function. • Plan must treat as expedited if requested by doctor

• Issued within 72 hours


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MEDICARE ADVANTAGE (MA)

Request reconsideration w/i 60 days of notice of the organization determination.

Reconsideration decision issued within• 30 days for standard reconsideration. • 72 hours for expedited reconsideration.

Unfavorable reconsiderations automatically referred to independent review entity (IRE). • Time frame for decision set by contract, not regulation

Unfavorable IRE decisions may be appealed • to ALJ • to MAC • to Federal Court


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MEDICARE ADVANTAGE (MA)

Fast-Track Appeals to Independent Review Entity (IRE) before services end for• Terminations of home health, SNF, CORF

• Two-day advance notice

• Request review by noon of day after receive notice

• IRE issues decision by noon of day after day it receives appeal request

60 days to request reconsideration by IRE• 14 days for IRE to act


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MEDICARE ADVANTAGE GRIEVANCE PROCEDURES

Grievance procedures to address complaints that are not organization determinations. • 60 after the event or incident to request grievance

• Decision no later than 30 days of receipt of grievance.

• 24 hours for grievance concerning denial of request for expedited review.


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PART D APPEALS PROCESS-OVERVIEW

Each drug plan must have an appeals process• Including process for expedited requests

A coverage determination is first step to get into the appeals process • Issued by the drug plan • An “exception” is a type of coverage determination

Next steps include• Redetermination by the drug plan• Reconsideration by the independent review entity (IRE)• Administrative law judge (ALJ) hearing• Medicare Appeals Council (MAC) review• Federal court


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PART D APPEALS PROCESS – COVERAGE DETERMINATION

A coverage determination may be requested by• A beneficiary • A beneficiary’s appointed representative• Prescribing physician

Drug plan must issue coverage determination as expeditiously as enrollee’s health requires, but no later than • 72 hours standard request

• Including when beneficiary already paid for drug

• 24 hours if expedited- standard time frame jeopardize life/health of beneficiary or ability to regain maximum function.


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EXCEPTIONS: A SUBSET OF COVERAGE DETERMINATION

An exception is a type of coverage determination and gets enrollee into the appeals process

Beneficiaries may request an exception• To cover non-formulary drugs

• To waive utilization management requirements

• To reduce cost sharing for formulary drug• No exception for specialty drugs or to reduce costs to tier for

generic drugs

A doctor must submit a statement in support of the exception


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PART D APPEALS - COVERAGE DETERMINATIONS ARE NOT AUTOMATIC

A statement by the pharmacy (not by the Plan) that the Plan will not cover a requested drug is not a coverage determination

Enrollee who wants to appeal must contact drug plan to get a coverage determination

Drug plan must arrange with network pharmacies• To post generic notice telling enrollees to contact plan

if they disagree with information provided by pharmacist or

• To distribute generic notice


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PART D APPEALS PROCESS –NEXT STEPS

If a coverage determination is unfavorable:• Redetermination by the drug plan.

• Beneficiary has 60 days to file written request (plan may accept oral requests).

• Plan must act within 7 days - standard• Plan must act within 72 hrs.- expedited

• Then, Reconsideration by IRE• Beneficiary has 60 days to file written request• IRE must act w/i 7 days standard, 72 hrs. expedited

• ALJ hearing• MAC review• Federal court


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PART D GRIEVANCE PROCESS

Each drug plan must have a separate grievance process to address issues that are not appeals

May be filed orally /in writing w/i 60 days Plans must resolve grievances

• w/i 30 days generally• w/i 24 hrs if arise from decision not to expedite

coverage determination or redetermination


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USEFUL WEBSITES

www.medicare.gov www.medicareadvocacy.org www.healthassistancepartnership.org www.nsclc.org

http://www.medicare.gov/

http://www.medicareadvocacy.org/

http://www.healthassistancepartnership.org/


CENTER FOR MEDICARE ADVOCACY, INC.

_________________

www.medicareadvocacy.org

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