Under Medicare law, Medicare Advantage plans and stand-alone Part D plans (“Plans”) must follow certain rules when enrollees disagree with Plan health care coverage determinations. Under the law, there are two distinct methods for raising issues with … [Read more...] about Disputes with Medicare Advantage Plans: Know the Difference Between Appeals and Grievances
Coverage & Appeals
Center for Medicare Advocacy Special Report | The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations
Artificial intelligence (AI)-powered decision-making tools that are used in health care utilization management (UM) are increasingly used by providers and plans to automate the medical review and prior authorization processes, direct post-acute care, … [Read more...] about Center for Medicare Advocacy Special Report | The Role of AI-Powered Decision-Making Technology in Medicare Coverage Determinations
MA Plans Allowed to Report Less Data about Appeals Outcomes
CMS rolls back beneficiary protection in the name of reducing “MA plan burden” and making things “easy to read” for eligible beneficiariesThe most urgent and frequent type of call we receive at the Center for Medicare Advocacy is from a Medicare … [Read more...] about MA Plans Allowed to Report Less Data about Appeals Outcomes
Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care
New Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility CareThe Centers for Medicare & Medicaid Services (CMS) — the federal agency responsible for administering the Medicare program — has begun … [Read more...] about Issue Brief: Medicare Payment vs. Coverage for Home Health & Skilled Nursing Facility Care
2020 Medicare Cost-Sharing Rates Released
On November 8, 2019, the Centers for Medicare & Medicaid Services (CMS) released the 2020 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.Each year, Medicare premiums, deductibles, and copayment … [Read more...] about 2020 Medicare Cost-Sharing Rates Released
Center Comments on Use of written Advance Beneficiary Notice of Noncoverage (ABN)
October 21, 2019VIA ELECTRONIC SUBMISSIONCenters for Medicare & Medicaid Services Department of Health and Human Services Attention: CMS-9115-P, Mail Stop C4-26-05 7500 Security Boulevard Baltimore, MD 21244-1850RE: … [Read more...] about Center Comments on Use of written Advance Beneficiary Notice of Noncoverage (ABN)
CMA Comments on “Patients Over Paperwork”
August 12, 2019SUBMITTED ELECTRONICALLY VIA www.regulations.govCenters for Medicare and Medicaid Services U.S. Department of Health and Human Services 7500 Security Boulevard Baltimore, MD 21244Re: CMS-6082-NC; Request for … [Read more...] about CMA Comments on “Patients Over Paperwork”
Beneficiary ALJ Appeals Continue to Get Priority at Office of Medicare Hearings and Appeals (OMHA)
Recent OMHA statistics show that beneficiaries[1] currently wait an average of 60 days[2] to obtain an Administrative Law Judge (ALJ) hearing and receive a decision. In contrast, non-beneficiaries (providers, suppliers, state Medicaid agencies, and … [Read more...] about Beneficiary ALJ Appeals Continue to Get Priority at Office of Medicare Hearings and Appeals (OMHA)
Practice Tip: Office of Medicare Hearings and Appeals Manual Can Be a Useful Tool
The Office of Medicare Hearings and Appeals (OMHA) is the agency that administers the Administrative Law Judge (ALJ) hearing program for Medicare Parts A, B, C and D appeals. OMHA has a Case Processing Manual that sets out day-to-day procedures for … [Read more...] about Practice Tip: Office of Medicare Hearings and Appeals Manual Can Be a Useful Tool
Objective Medicare Appeals Jeopardized By New ALJ Selection Process
On July 10, 2018, the President signed an Executive Order undermining the impartial hiring of Medicare Administrative law Judges (ALJs). The Order states that “conditions of good administration make necessary an exception to the competitive … [Read more...] about Objective Medicare Appeals Jeopardized By New ALJ Selection Process