Copyright © Center for Medicare Advocacy, Inc. MEDICARE APPEALS Families USA Conference January 26, 2007 Vicki Gottlich Center for Medicare Advocacy Heather Bates Health Assistance Partnership Kelly Brantley Health Assistance Partnership ______________

Copyright © Center for Medicare Advocacy, Inc. 2 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

Copyright © Center for Medicare Advocacy, Inc. 3 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

Copyright © Center for Medicare Advocacy, Inc. 4 EXPEDITED APPEALS PROCESS – MEDICARE PARTS A & B Beneficiary not liable until later of 2 days after date of notice or termination date opOfPage (describes expedited determination (ED) and other notice requirements) opOfPage

Copyright © Center for Medicare Advocacy, Inc. 5 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.

Copyright © Center for Medicare Advocacy, Inc. 6 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

Copyright © Center for Medicare Advocacy, Inc. 7 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

Copyright © Center for Medicare Advocacy, Inc. 8 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

Copyright © Center for Medicare Advocacy, Inc. 9 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

Copyright © Center for Medicare Advocacy, Inc. 10 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

Copyright © Center for Medicare Advocacy, Inc. 11 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)

Copyright © Center for Medicare Advocacy, Inc. 12 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

Copyright © Center for Medicare Advocacy, Inc. 13 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

Copyright © Center for Medicare Advocacy, Inc. 14 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

Copyright © Center for Medicare Advocacy, Inc. 15 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

Copyright © Center for Medicare Advocacy, Inc. 16 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.

Copyright © Center for Medicare Advocacy, Inc. 17 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

Copyright © Center for Medicare Advocacy, Inc. 18 PART D APPEALS PROCESS – COVERAGE DETERMINATION A coverage determination may be requested by A beneficiary A beneficiarys appointed representative Prescribing physician Drug plan must issue coverage determination as expeditiously as enrollees 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.

Copyright © Center for Medicare Advocacy, Inc. 19 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

Copyright © Center for Medicare Advocacy, Inc. 20 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

Copyright © Center for Medicare Advocacy, Inc. 21 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

Copyright © Center for Medicare Advocacy, Inc. 22 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

Copyright © Center for Medicare Advocacy, Inc. 23 USEFUL WEBSITES

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