• What services are covered by Medicare Part A?

• What services are covered by Medicare Part B?

• How can I appeal a Medicare denial?

• What are my rights and responsibilities regarding the New Prescription Drug benefit?

For other information, follow one of the links below or scroll down the page.

Generally, coverage is available when services are medically reasonable and necessary for treatment or diagnosis of illness or injury.

Part A Coverage

• Inpatient hospital services (note: the appeals process for Inpatient Hospital Services currently differs from the standard process outlined below).

• Inpatient skilled nursing facility services

• Some home health Services

• Hospice services

Part B Coverage

• Physicians' services;

• Some home health Care;

• Services and supplies, including drugs and biologicals which cannot be self-administered, furnished incidental to physicians' services;

• Diagnostic x-ray tests, diagnostic laboratory tests, and other diagnostic tests;

• X-ray therapy, radium therapy and radioactive isotope therapy;

• Surgical dressings, and splints, casts and other devices used for fractures and dislocations;

• Durable medical equipment;

• Prosthetic devices;

• Braces, trusses, artificial limbs and eyes;

• Ambulance services;

• Some outpatient and ambulatory surgical services;

• Some outpatient hospital services;

• Some physical therapy services;

• Some occupational therapy;

• Some outpatient speech therapy;

• Comprehensive outpatient rehabilitation facility services;

• Rural health clinic services;

• Institutional and home dialysis services, supplies and equipment;

• Ambulatory surgical center services;

• Antigens and blood clotting factors;

• Qualified pyschologist services;

• Therapeutic shoes for patients with severe diabetic foot disease;

• Influenza, Pneumococcal, and Hepatitis B vaccine;

• Some mammography screening;

• Some pap smear screening, breast exams, and pelvic exams;

• Some other preventive services including colorectal cancer screening, Diabetes training tests, bone mass measurements, and prostate cancer screening.

For more details, see our Medicare Part B page.

Standard Appeals Process for Part A and Part B:

1.    Redetermination

• No minimum claim amount

• Must be filed within 120 days of receipt of "Initial Determination"

• Filed with Medicare Contractor

• Reviewed and decided by Medicare Contractor

2.    Reconsideration Determination

• No minimum claim amount

• Must be filed within 180 days of receipt of "Redetermination"

• Filed with Qualified Independent Contractor (QIC)

• Reviewed by Qualified Independent Contractor (QIC)

• Decisions must be issued within 60 days, or case can be escalated to ALJ, below

3.    Administrative Law Judge (ALJ) Hearing 

• Amount in controversy must be at least $120.00**

• Must be filed within 60 days of receipt of "Reconsideration Determination"

• Filed with Qualified Independent Contractor (QIC)

• Reviewed and decided by an Administrative Law Judge from the U.S. Dept of Health and Human Services

4.    Medicare Appeals Council (MAC)

• Amount in controversy must be at least $120.00**

• Must be filed within 60 days of receipt of ALJ "Hearing Decision"

• Filed with U.S. Dept of Health and Human Services

• Reviewed and decided by U.S. Dept of Health and Human Services Medicare Appeals Council

5.    Judicial Review

• Amount in controversy must be at least $1,180.00**

• Must be filed within 60 days of receipt of "MAC Decision"

• Filed with U.S. District Court

• Reviewed and decided by U.S. District Court

Expedited Review

Beneficiaries may seek "expedited review" of a skilled nursing facility, home health, hospice or comprehensive outpatient rehabilitation facility (CORF) services discharge or termination.

Expedited review is available in cases involving a discharge from the provider of services, or a termination of services A reduction in service is not considered a termination or discharge for purposes of triggering expedited review except in the case of skilled nursing facility care when the reduction of care from daily to intermittent will mean that the beneficiary is no longer eligible for Part A coverage.  For home health care and CORF services, a successful appeal requires that a physician certify that "failure to continue the provision of such services is likely to place the individual's health at risk."  

The provider must give the beneficiary a general, standardized notice at least two days in advance of the proposed end of the service. If the service is fewer than two days, or if the time between services is more than two days, then notice must be given by the next to last service.  The notice describes the service, the date coverage ends, the beneficiary's financial liability for continued services, and how to file an appeal.

A beneficiary who wishes to exercise the right to an expedited determination must submit a request for a determination with the QIO in the state in which the beneficiary is receiving the services at issue. The request may be made in writing or by telephone, but the request must be made no later than noon of the calendar day following receipt of the provider's notice of termination. If the QIO is unavailable to accept the beneficiary’s request, the beneficiary must submit the request by noon of the next day the QIO is available.  At that time, the beneficiary is given a more specific notice that includes a detailed explanation of why services are being terminated, a description of any applicable Medicare coverage rules and information on how to obtain them, and other facts specific to the beneficiary’s case. The beneficiary is not financially liable for continued services until two days after receiving the notice, or the termination date specified on the notice, whichever is later.

Coverage of the services at issue continues until the date and time designated on the termination notice, unless the QIO reverses the provider’s service termination decision.  If the QIO’s decision is delayed because the provider did not timely supply necessary information or records, the provider may be liable for the costs of any additional coverage, as determined by the QIO.  If the QIO finds that the beneficiary did not receive valid notice, coverage of the provider services continues until at least 2 days after valid notice has been received.  Continuation of coverage is not required if the QIO determines that coverage could pose a threat to the beneficiary's health or safety.

If the QIO upholds the decision to terminate services or discharge the beneficiary, the beneficiary may request expedited reconsideration, orally or in writing, by noon of the calendar day following the QIO's initial notification. The reconsideration will be conducted by the QIC, which must issue a decision within 72 hours of the request. If the QIC does not comply with the time frame, the beneficiary may "escalate" the case to the administrative law judge level.

Beneficiaries retain the right to utilize the standard appeals process rather than the new expedited process in all situations. A QIO may review an appeal from a beneficiary whose request is not timely filed, but the QIO does not have to adhere to the time frame for issuing a decision, and the limitation on liability does not apply.

Special Rules for Hospital Claims

Hospital inpatients denied Medicare during their stay may request an "expedited

review’" of a Medicare denial by the QIO.  These expedited requests must be decided by the QIO within three working days.

Under previous regulations, a hospital inpatient who received a denial notice from the hospital and requested review immediately avoided being charged until the QIO issued an initial determination. However, the new expedited appeals regulations protect only those inpatients who did not know or could not reasonably have been expected to know that payment would not be made from liability.

A beneficiary may request reconsideration review by the QIC for an unfavorable decision .  If the reconsideration decision is unsatisfactory and at least $200 remains in controversy, the beneficiary may request an ALJ hearing.  Hearing requests must be made within 60 days of receipt of the notice of the reconsideration decision.  The hearing request should be made in writing and should be filed with the entity identified in the reconsideration notice.
 

If the hearing request is unsatisfactory, a beneficiary may request a review from the Medicare Appeals Council (MAC). The request must be made within 60 days of receipt of the hearing decision. If $2,000 remains in controversy after the hearing, the case may proceed into United States District Court.

Medicare Advantage ("Medicare Part C", "Medicare Managed Care") Appeals

Medicare Part C establishes a different appeals process for Medicare Advantage (MA) cases, including those from HMO, PPO, SNPs, and PFFS plans.  In MA cases, initial determinations are known as "organization determinations."  Organization determinations as well as the next level of review, reconsideration determinations, are made by the MA plan.  If a reconsidered decision is denied in whole or in part, it is sent automatically to the Maximus Center for Health Dispute Resolution (Maximus CHDR), an external review organization hired by CMS to review Medicare HMO reconsidered decisions.  The CHDR decision may be appealed to an ALJ, as in Part A or Part B appeals above.

In addition, MA plans are required to have internal grievance procedures.  They must provide information to members regarding this grievance process in the plan’s written membership rules, along with timetables and information about the steps necessary to utilize the grievance process. The grievance procedures are to be used in all cases that do not involve an "organization determination." For example, controversies about hours of service, location of facilities, or courtesy of personnel would go through the grievance process.

_______________________

**Amount in controversy is increased by the percentage increase in the medical care component price index.

DISCHARGE PLANNING ADVOCACY TIPS FOR MEDICARE PATIENTS

Introduction

The following information for Medicare beneficiaries and their advocates is useful in challenging a discharge or reduction in services in hospital, skilled nursing, and home health care settings. In approaching any discharge situation, it is important that beneficiaries, those assisting them, or acting on their behalf do the following:

• Read carefully all documents that purport to explain Medicare rights.

• Question treating physicians, nurses, social workers, home health care providers, and other care providers about necessary services as the beneficiary’s condition either improves, remains the same, or requires more services.

• If there are questions and concerns about care, voice them and participate fully in all care decisions.

• Become familiar with Medicare guidelines about eligibility for hospital, home and community based care.

• Identify and become familiar with the health care services available in the local community.  Important sources of information about services include the Elder Care Locator 1-800-677-1116 and the Medicare program’s information line – 1-800-MEDICARE (1-800-633-4227) (TTY: 1-877-486-2048 for the hearing impaired).

• Use physicians and suppliers who are Medicare participating providers.  They have agreed to accept the Medicare reasonable charge amount, less the 20% beneficiary co-payment, as payment in-full for Medicare-covered physician and supplier services (See, 42 U.S.C. §§1395u(b)(3);1395n; 42 C.F.R. §§410.152; 424.55(b).

• Contact the local Medicare office or the Social Security office for a list of Medicare participating providers and suppliers or check online at Medicare.gov - About the Physicians Directory.

• See CMS’ memorandum (7/13/07) to State Survey Agency Directors about enforcement of the requirement that hospitals provide Medicare beneficiaries notice of their rights, including discharge appeal rights, as well as sample discharge notices.

• On July 2, 2007, per the Centers for Medicare & Medicaid Services (CMS) a final rule became effective which governs notification to Medicare beneficiaries of their hospital and critical access hospital discharge appeal rights. As an aide to beneficiaries and their advocates, we have provided several key documents related to this rule:

  • Memorandum from Thomas E. Hamilton, Director of the Survey and Certification Group at CMS, to State Survey Agency Directors regarding the implementation of the final rule.

  • CMS standardized hospital discharge notice, “An Important Message from Medicare about Your Rights."

  • CMS standardized hospital discharge notice in Spanish, “Mensaje Importante de Medicare sobre Sus Derechos.”

Below are links to .pdf versions of discharge planning fact sheets for beneficiaries and advocates

Coverage & Appeals Articles And Updates

• Medicare's policy that requires beneficiaries to submit evidence along with their requests unfairly hinders people's ability to appeal. - May 1, 2008

• Did you know that Medicare Part B offers some coverage for footcare? - March 13, 2008

• Medicare Coverage Of Eyeglasses And Low Vision Devices - September 20, 2007

• Medicare Coverage Of Dental Services - June 7, 2007

• The Continuing Saga Of Part D Appeals - April 12, 2007

• Some Beneficiary Concerns About The Medicare Part D Appeals Process - June 1, 2006

• Medicare Drug Payments: Is It D Or Is It B? - March 16, 2006

• What To Do If You Can't Get Medications You Need From Your Medicare Prescription Drug Plan - January 19, 2006

• A New Meaning To “Independent” In Qualified Independent Contractor (QIC) - November 17, 2005

• Senator Christopher J. Dodd (D-CT) Seeks To Ensure Access To Impartial Hearings Before Administrative Law Judges For Medicare Beneficiaries - July 7, 2005

• CMS Issues Preliminary Instructions For Expedited Review Of Certain Claims (.pdf) - June 30, 2005

• Will My Prescription Drug Be Covered Under Medicare Part D? (Part 2) (.pdf) - June 16, 2005

• Will My Prescription Drug Be Covered Under Medicare Part D? (.pdf) - June 9, 2005

• Case Filed Challenging New Regulation That Denies Notices Of Initial Determination To Medicare Beneficiaries' Representatives (.pdf) - May 26, 2005

• Access To Power Wheelchairs Still Limited By "For Use In The Home" Requirement (.pdf) - May 12, 2005

• Understanding The Medicare Secondary Payer (MSP) Program - April 21, 2005

• Changes To Medicare Appeals Council Review: Another Obstacle To Success On Appeal? - April 7, 2005

• Changes To The Medicare Administrative Law Judge Hearing Process - March 31, 2005

• The Times They Are A Changin': New Time Frames And Processes For Medicare Appeals - March 23, 2005

• Emergency Ambulance Services - February 28, 2005

• Restrictions Remain On Power Wheelchairs and Other Assistive Devices: CMS Seeks Comments On Proposed National Coverage Decision - February 24, 2005

• Medicare Part D Appeals: A Mixed Bag for Beneficiaries - February10, 2005

• Federal Judge Issues Final Order Requiring Home Health Agencies To Provide Written Notice Of Intended Adverse Action - December 28, 2004

• Amount In Controversy Needed For An ALJ Hearing To Remain The Same In 2005; Amount Will Increase For Those Appealing In Federal Court - December 28, 2004

• CMS Opens National Coverage Determination (NCD) Review On Criteria For Wheelchairs - December 17, 2004

• New Medicare Expedited Appeals Process: What Do Beneficiaries Gain? - December 9, 2004

• Changes To The Medicare Appeals System Are Likely To Delay Access To Impartial Hearings - November 11, 2004

• Will Medicare Beneficiaries Get A Fair Hearing? GAO Reports On Plan To Transfer Administrative Law Judges- October 7, 2004

• Center Submits Comments On Proposed Transfer Of Administrative Law Judges - July 28, 2004

• Courts Extend Benefits Of Liberalized Medicare Coverage Rules To Pending Cases - July 15, 2004
  

• CMS Policies May Deny Coverage That Should Be Granted According To Medicare Law: Medicare Decision Makers Must remain Autonomous - June 17, 2004
  

• SSA And HHS Disclose Their Plan To Transfer Administrative Law Judges (ALJs) - April 1, 2004
  

• Medicare Ordered To Apply Liberalized National Coverage Rules To Pending Claims - February 5, 2004
  

• Proposed Medicare Appeals Regulations Would Change Nature Of ALJ Review Other Important Changes Also Proposed - October 23, 2003
  

• Center For Medicare Advocacy's Actions Result In CMS Requiring Durable Medical Equipment Carrier To Issue Proper Notices - March 25, 2003

• CMS Issues Notice Concerning Appeals Of Claims Under Medicare Parts A And B - October 24, 2002