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On August 1, 2016, Judge Jeffrey Meyer of U.S. District Court in Connecticut granted final approval to a settlement agreement that will ensure timely decisions for Medicare beneficiaries who appeal denials of coverage to Administrative Law Judges (ALJs).

The nationwide class action, Exley v. Burwell, 3:14-CV-1230, was brought by six individuals who waited longer than the time limit guaranteed by law for decisions on their appeals.  The plaintiffs had appealed for coverage of items and services such as medically necessary ambulance transport and care in a skilled nursing facility. They incurred financial liability for those services, and were supposed to receive decisions within 90 days of requesting a hearing.  However, they had to wait much longer.

Stephen Lessler of Connecticut waited over nine months for a decision on his ALJ appeal for coverage of nursing facility care.  He finally received a favorable decision allowing a refund – but the decision was issued the day after he died. Stephen Lessler’s son, Robert Lessler, said, “Justice for my father was delayed just a bit too long.  I am very pleased to know that through this litigation and the work of the Center for Medicare Advocacy, no more Medicare beneficiaries will endure a similar delay.”

The settlement calls for placing beneficiaries at the front of the line for receiving ALJ hearings and decisions. While the Office of Medicare Hearings and Appeals (OMHA) has been overwhelmed by requests for hearings in recent years, it has recognized that beneficiaries are the most vulnerable of appellants. The vast majority of appellants are medical providers such as hospitals and suppliers – beneficiaries comprise only 1 to 2% of those requesting ALJ hearings.  Prioritizing beneficiary appeals has negligible effect on the system as a whole while ensuring timely decisions for those who need them most

OMHA has already instituted the policy of prioritizing beneficiary appeals, with a positive effect on wait times. The settlement ensures that this policy will continue for at least three years.  The settlement also calls for certain measures that will make the appeals system easier for beneficiaries to use, such as revisions to forms and instructions, and the establishment of a specially-designated OMHA staffperson to handle inquiries and problems related to beneficiary appeals. OMHA will also publish monthly data on its website showing processing times for beneficiary appeals.

ALJ hearings are particularly important for beneficiaries because they represent the only opportunity in Medicare’s appeal system for a live hearing, with presentation of testimony and an exchange with the adjudicator.  The other levels of appeal happen only “on the record,” without a live hearing. The Center is confident that the settlement in Exley will help ensure timely access to ALJ hearings and decisions on Medicare issues that are critical to beneficiaries.

A copy of the settlement is available here.

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