Document
(specify
notice, instructions, burden estimates)
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Page #
(if
applicable)
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Comment
(commenter
and summary of comment)
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CMS Response
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Notice
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All
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Gail
Coleman
Commonwealth
Care
1.
Commenter notes that Medicare and Medicaid appeal time frames are
different and believes it is unclear what day limits CMS wants
plans to use because the two processes are not yet integrated.
2.
Commenter suggests several specific changes to the notice,
including changes to optional terms included in various brackets
and wording changes to make it clearer that certain sections apply
to requesting an appeal from the plan (as opposed to a State Fair
Hearing). Specifically, commenter believes:
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“Denied” should be in brackets
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“Doctor” should be placed in brackets
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Keep the “Appeal” section for Medicare appeals
exclusively and State Fair Hearing section for Medicaid appeals
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Retain header on p. 2 (“Important Information About Your
Appeal Rights”)
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On p. 2 make it clearer which sections relate to the plan appeal
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On p. 3 add, make it clear what the enrollee should include with a
SFH request
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Revise the “Get help” section to make it clearer that
the enrollee can contact the plan, add plan hours of operation and
indicate that 1-800-Medicare can be reached 24/7.
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1.
CMS acknowledges that the timeframes for requesting Medicare and
Medicaid appeals differ, but expects health plans to work with the
State Medicaid agency to insert the appropriate Medicaid time
limits for requesting an appeal, as applicable. Under the “You
have the right to appeal our decision” section, 2nd
paragraph, plans have the option to insert a State Medicaid
timeframe for requesting an appeal if the service that was denied
(and subject to an appeal request) is a Medicaid service.
Accordingly, we
did not accept the commenter’s suggestion to remove the
bracketed option for inserting the State Medicaid timeframe (if
different from Medicare) for plan level appeals. As noted above,
we believe the plan should have the flexibility to insert the
Medicaid timeframe for requesting an appeal, as appropriate.
2.
Per commenter’s suggestion, we have included “denied”
as an option in the curly brackets in the sections “Your
request was denied” and “Why did we deny your
request?” (as opposed to having it as the default option)
since, under Medicare Advantage rules, the notice may also be used
for a reduction or discontinuation of a previously authorized
course of treatment. We also changed “terminated” to
“stopped” for purposes of plain language/clarity.
We
did not accept the suggestion to add the term “doctor”
to the brackets with “provider” and have retained
“doctor” as the default option. Under Medicare
Advantage regulations, only a physician is permitted to request an
appeal on an enrollee’s behalf; this does not apply to other
providers so we believe it would be misleading to suggest that
another type of provider could request the appeal on the
enrollee’s behalf without being the enrollee’s
appointed representative. We have retained “provider”
in hard brackets as a Medicaid option.
Per
commenter’s suggestion, we have added specific instructions
for the information that should be included with a request for a
State Fair Hearing (name, address, member #, reasons for
appealing, evidence to include with request).
We
also accepted the comment to add a field for the plan’s
hours of operations and a notation that 1-800-Medicare can be
contacted 24 hours per day/7 days per week.
We
also accepted other suggestions made by the commenter, including
adding text to make it clearer which sections apply strictly to
requesting a plan appeal and retaining the header on page 2 (on
currently approved CMS-10003) that states the notice contains
important information about appeals rights.
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Notice
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All
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David
Certner
Legislative
Counsel and Legislative Policy Director
AARP
1.
Without clear language on the form and clear instructions to
Medicare health plans, the new form could increase confusion for
beneficiaries who are eligible for Medicare and full Medicaid
under a state Medicaid plan.
2.
While AARP lauds CMS’ goal of creating an integrated form,
it believes that the form does not clearly explain the differences
between Medicare and Medicaid
3.
The difference between an appeal and a state fair hearing is not
explained fully
4.
The form should contain an upfront explanation of how to
understand the form itself and what information is being
presented.
5. If the beneficiary is dually
eligible, the form should explicitly state that there is a
difference between Medicare and Medicaid appeals procedures. In
addition, the form should state which process is being used to
adjudicate the denial decision.
6. If the beneficiary is denied
Medicaid benefits and is entitled to a State Fair Hearing, the
form should clearly describe the differences between the health
plan's appeal process and a State Fair Hearing. It should also
explain why a beneficiary may want to file a health plan appeal
and a State Fair Hearing concurrently (if applicable).
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1.
CMS believes that the notice and instructions provide clear
guidance to health plans. The notice combines the Notice of
Denial of Medical Coverage and the Notice of Denial of Payment
which are currently in use. Further, CMS has offered health plans
optional language that can be used to customize the letter to make
communication as clear as possible to beneficiaries if a Medicaid
service is denied.
2.
CMS agrees that integrating the notices will promote better
access to the appeals process for beneficiaries. The form will
communicate denial of services and payments in one document,
making it easier for beneficiaries to understand and will also, as
appropriate, include information on Medicaid appeal rights.
3.
The form requires an explanation of the appeals and state hearing
processes. Given variances in Medicaid appeals processes, plans
will be responsible for populating certain information in free
text fields.
We
believe the level of detail the commenter is proposing is more
appropriately set forth in the plan’s Evidence of Coverage
(EOC). This is a notice that seeks to highlight the key aspects
of the appeal processes so the enrollee is made of aware of next
steps to take to dispute the plan’s decision. It is not
intended to replace the more thorough explanation provided in the
EOC.
4.
We have added some additional instructional information to the
notice in an effort to enhance clarity. For example, we’ve
added a statement to the top of the notice explaining that the
notice contains important information about the enrollee’s
right to appeal and directs enrollees to the contact section on
the last page if the enrollee needs assistance. Further, we
believe the sections such as “We denied your request”
and “Why did we deny your request?” make the form
fairly straightforward and easy to understand. Again, the notice
is not intended as a substitute for the Evidence of Coverage.
5.
We believe the free text fields are an appropriate place for
health plans to explain why coverage has been denied and that the
notice distinguishes between the two processes. Given that each
State has its own Medicaid appeals rules, not all of the language
that will need to be included in the notice can be standardized.
6.
Health plans have the flexibility through the optional language,
“[Insert, if applicable:
and/or you can request a State
Fair Hearing. You can ask for both types of review at the same
time, as long as you meet the deadlines]”
to explain why it is better to pursue both processes
simultaneously. Per comments we received, we have added text to
attempt to more clearly distinguish plan appeals from SFHs. The
notice is not meant to replace the more expansive appeals
information provided in the plan’s Evidence of Coverage or
effective advocacy for appropriate services.
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Notice
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All
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Ann Berg
Deputy Medicaid Director
Minnesota
Department of Human Services
1.
The form should allow for additional identifying fields in the
member identification section to allow health plans under contract
with State Medicaid agencies to assist the member in identifying
the service being denied such as the member’s Medicaid or
PMI number, provider of the service being denied, authorization
request, date of action and first date of service (as applicable).
2.
The form should provide space for Medicaid contacts in the get
help and more information section such as a state ombudsman for
managed health care.
3.
The form should require a
notification section specifying who else received a copy of the
letter if required by the state
Medicaid agency. For example, Minnesota requires that the
provider and ombudsman also receive a copy of the notices of
denial.
4.
The use of the word “optional” also makes it unclear
whether Medicare health plans must use an integrated Form
CMS-10003 in all cases where a Medicare health plan enrollee also
receives full Medicaid benefits that are being managed by the
Medicare health plan. If CMS intends to require this form to be
used in all such cases, CMS should work with State Medicaid
agencies in advance of requiring the form to allow successful
implementation and protection of beneficiaries.
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1.
We have modified the notice to accommodate additional fields to
insert Medicaid related information, such as a member
identification number, the provider whose service is being denied,
authorization request, date of action and first date of service,
as applicable.
2.
We have modified the notice to include a field for adding state
Medicaid contacts.
3.
We have modified the notice to include a field to insert the names
of persons or State agencies who also received a copy of the form.
4. Use of CMS-10003 is mandatory under
the Medicare Advantage (Part C) program. In addition, CMS expects
health plans that manage benefits for enrollees who are eligible
for both Medicare and Medicaid to use the notice in cases where a
Medicaid service has been denied, which is why the optional
Medicaid language has been included. CMS will work with State
Medicaid agencies to ensure successful implementation of the new
integrated form.
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Notice
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PA
15222 (unidentified commenter)
Commenter
requests sufficient notification be given prior to the compliance
effective date in order to allow plans time to update systems,
test, and implement use of the form.
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When
determining the date plans must begin using the integrated denial
notice (following OMB approval), we will consider plans’
need to update and test systems in order to implement use of the
notice.
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Notice
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Kim Piper
Group
Health Cooperative
Commenter
is concerned that use of this integrated denial notice will be
burdensome for plans who use the EOB for payment denials and would
require massive systems changes that would be onerous to
implement. Requesting 2 years for implementation.
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While
commenter does not provide specifics on the types of system
changes that would constitute “massive” changes, we
recognize that plans using the EOB for payment denials will have
to reprogram systems to include the newly approved standardized
text of CMS-10003 (for use in Medicare payment denials). We will
take this into consideration when determining an implementation
deadline following OMB approval.
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Notice
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p.
1
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Thomas Campbell
Gateway
Health Plan
1.
Commenter asks that the word “suspended” be defined,
as used in this notice.
2.
Commenter asks that we confirm that one of the terms in the
brackets is intended to replace the word “denied”.
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1.
CMS defines “suspended” as a temporary stoppage of a
service. We will include this clarification in the instructions.
2.
We have modified these sections of the notice such that “denied”
is included as an optional term within the brackets. The
instructions are clear that the plan should select the appropriate
term shown in the brackets (e.g., “denied,”
“reduced”). For further clarity, we’ve added a
brief instruction within the brackets to “insert appropriate
term.”
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Notice and burden estimates
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Tribal Technical
Advisory Group
Alaska
Native Tribal Health Consortium
National
Indian Health Board
These
3 organizations submitted the same comments, most of which were
outside the scope of this effort. For example, these
organizations “encourage the Secretary to draw upon the
guidance issued under this regulation in fashioning the denial and
appeal policies for the Exchanges.” Other statements appear
to relate to FFS appeals, but this notice only applies in the
managed care setting.
Commenters
also observed that the burden does not include an estimated burden
for patients and their providers to respond.
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The
comment related to the exchanges is outside the scope of this PRA
package. The purpose of revising this existing package is to make
necessary changes to the denial notice. It doesn’t affect
underlying coverage and payment policies and will not apply to the
Exchanges. It’s not clear which “regulation”
the commenter was referring to (again, this is a PRA package, not
a rulemaking). The commenter also makes statements that appear to
relate to FFS appeals, but this form is used in the managed care
context exclusively. Commenter also seeks clarification on whether
this notice applies in the Part D context, which it does not; the
applicability of this notice is set forth in the supporting
statement.
The
commenter is correct that the burden estimates do not account for
a patient or provider “responding” to the notice.
This would be outside the necessary burden estimates for this
package; the burden estimate in this package properly accounts for
the time/cost for a health plan to complete the notice when
services are denied, reduced or stopped.
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