60 Day Public Comment Response

Summary of Comments and Responses for 60-day PRA Coverage Decision Letter (CDL)

Comment
A health plan commented that the draft CDL does not include a
space to insert the enrollee’s address block and is requesting to
add it to show through a window envelope.

Response
We appreciate the comment but decline to include an address block
on the coverage decision letter (CDL). The Medicare Advantage
(MA) and Medicare-Medicaid Plan (MMP) integrated denial notices
(IDN) similarly do not include a space for an address block on the
notice. Additionally, adding an address block pushes key content
below the first page that is important for overall understanding of the
CDL.

A state Medicaid agency suggested the new information added
below the header that is currently centered should be aligned to the
left for better readability. It also recommended rewording the first
paragraph so that it is in plain language. Finally, this commenter
suggested adding information into the section on continuation of
benefits pending appeal to include information on paying for
services if the appeal is adverse to the enrollee.

We agree the text at the top of the CDL should be left-aligned so
that it is easier to read and have updated the language accordingly.
We also appreciate the comment on using plain language in the first
paragraph. We conducted extensive beneficiary testing of the CDL
and drafted it based on findings and feedback from enrollees and
their caregivers. Thus, at this time, we decline to make broad
changes to the language in the CDL. We welcome commenters to
suggest alternatives to certain words or phrases for consideration.
The last comment suggested that we add language in the
continuation of benefits section to notify an enrollee they may have
to pay for services if their appeal is adverse. We appreciate the
comment; however, applicable integrated plans (AIP) and states may
not pursue recovery for costs of services furnished during the
integrated reconsideration per 42 CFR 422.632(d)(1). We decline
adding the suggested language to the CDL.

Multiple health plans suggested changing the fields that read
“” to “” where displayed through
the CDL.

We accept this edit and will change language throughout the CDL to
state “medical service/item.” This is also consistent with language
used in the MA and MMP IDNs.

A health plan suggested updating language in a few sections of the
CDL to reduce plan burden and enrollee confusion. On page 1, the
commenter suggested combining the sentences “Our plan [Insert if applicable: payment for] the listed
below:” and “Our plan made this decision because:”

suspended or changed and a separate field to describe why it was
denied. Those are distinct fields that should remain separate so the
enrollee can clearly understand what was denied and why.

On page 2, the commenter noted the administrative burden to
include specific dates to appeal by instead of stating they must
appeal within 60 days and was concerned this would cause data
entry errors.

The requirement to include the exact date to appeal by in the CDL
has been included in the previous version, so this is not a new
burden on plans. Plans must already calculate the deadline for
receipt of an appeal for internal record-keeping and including this
exact date is an important element of the CDL to reduce enrollee
confusion.

The commenter also suggested replacing language in the
continuation of benefits section and remove the fields where a
specific date is filled in and replace it with 10 calendar days or
remove it altogether.

We have bracketed the continuation of benefits section so that plans
have the option to remove this language if the denial is not related to
a previously approved medical service/item. However, if the denial
is related to a previously approved service, including the exact date
to request a continuation of benefits is an important element to
reduce enrollee confusion.

Multiple health plans requested to be allowed to keep the section
titled “How to keep getting your medical service/item during your
appeal” that is newly bracketed. The comments stated removing
this section would result in unnecessary customization and
required costly reconfiguration in their system. Commenters also
had concerns with version control and staff inappropriately
removing this paragraph.

We appreciate the comments and agree keeping this paragraph in the
CDL is permissible if it causes undue burden to remove it or there
are concerns with version control. We have updated the instructions
in the CDL to make it optional for plans to remove the language.

An advocacy organization appreciated language added to the CDL
that improved readability and reduced confusion for the enrollee.
They expressed concern that new language for post-service cases
was confusing and needed further explanation: “Please note, you
will not be billed or owe any money for this [insert as applicable:
medical service/item or Part B drug or Medicaid drug].” It also
suggested that CMS add language regarding continuing of care
during appeal to the beginning of the CDL.

We appreciate the feedback on the language added to improve
readability and reduce confusion. We agree that ensuring
understanding of the content is an important element of the CDL.
We welcome the comment but will maintain the current language for
payment cases where the enrollee has no liability. The CDL is only
used by AIPs. The language in the Medicare fee-for-service advance
beneficiary notice is not applicable to AIP enrollees because they are
full-benefit dually eligible individuals who cannot be separately

billed by providers. We decline to include the requested language in
the CDL so that it does not cause confusion for enrollees.
We also appreciate the comment to add language at the beginning of
the CDL regarding continuing benefits during an appeal. We have
added the following sentence to refer the enrollee to the section later
on in the CDL: “See the ‘How to keep getting your during your appeal’ section later in this CDL for
information about continuing to receive your
during your appeal.”
A health plan suggested moving language about stopping,
suspending, reducing previously approved services to after the
second paragraph.
The plan inquired about the new disposition “changed” that was
added to the CDL and how to identify those cases for reporting
purposes.

We appreciate the suggestion to move language regarding stopping,
suspending, reducing previously approved services to after the
second paragraph. However, we decline to move the language as it is
currently included above the information on appeal rights. Based on
findings from testing of this form with enrollees and their caregivers,
we have deliberately sequenced the information in the form to align
with the sequence of steps in the appeals process.

The plan also inquired about the language that states “You can’t
get a fast appeal if our plan denied payment for a service you
already got” when enrollees can request a fast appeal for payment
denials.

We refer plans to the Medicare Part C Reporting Requirements and
Technical Specifications to review the requirements for reporting
Medicare Part C decisions. Requests that are changed would be in
the partially denied or adverse category for reporting. 1
We welcome the comment on language in the CDL that states “You
can’t get a fast appeal if our plan denied payment for a service you
already got” that contradicts our policy guidance. We have removed
this language as it is not consistent with our policy in the Addendum
to the Parts C & D Enrollee Grievances, Organization/Coverage
Determinations, and Appeals Guidance for Applicable Integrated
Plans2 that does allow fast appeals for payment denials. Thank you
for bringing this to our attention.

Medicare Part C reporting requirements can be found on CMS’ website: https://www.cms.gov/medicare/health-plans/healthplansgeninfo/reportingrequirements.
The Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance for Applicable Integrated Plans can be found on CMS’
website: https://www.cms.gov/files/document/dsnpartscdgrievancesdeterminationsappealsguidanceaddendum.pdf.
1
2

An advocacy organization appreciated the improvements to the
CDL that make it more readable and navigable. It also encouraged
CMS to conduct consumer testing when possible to ensure the
legal information in letters is presented in a manner that is easy to
read and navigate.

We appreciate the feedback on the language added that makes the
CDL more readable and navigable. We also appreciate the comment
on conducting consumer testing and agree it is important to engage
with enrollees to ensure the CDL is understandable to those who will
receive it.

A health plan inquired whether the CDL could be adjusted for
coverage decisions for multiple services or items. On the first
page, it commented that including the outcome twice was
redundant with the paragraph that informs the enrollee about the
decision made. The health plan also questioned whether it could
provide the information in a grid format instead of a narrative to
ensure consistency and ease of enrollee understanding.

Plans are permitted to include multiple coverage decisions in the
CDL as long as the outcome for each decision is clear.

The plan suggested in the section “What happens next” to include
“after the appeal” in the header so that it is clearer that section is
referring to after the appeal.

We appreciate the comment that the outcome is repeated in the
second paragraph of the CDL, however, we decline changing the
italicized instructions to plans. This language includes suggested
content to include when providing information on the outcome to
ensure the enrollee understands the decision. Plans may provide the
outcome in a grid format as long as it includes all required
information and is clear to the enrollee. We also suggest the grid
does not take up too much space causing the information below it to
be pushed down significantly in the CDL.
We appreciate the comment on renaming the section “What happens
next” to include “after the appeal” at the end of the header. We are
not accepting this change since the line under the title starts by
stating “After the appeal” so it is already clear to the reader what
that section discusses.

A state Medicaid agency supported the new elements incorporated
into the updated CDL that make it clearer and more
understandable. It especially appreciated instructional text in the
introduction of the CDL and plain language explanations of the
decision. The state Medicaid agency encouraged CMS to require
plans attest to using plain language throughout the CDL.
The commenter included recommendations to strengthen areas in
the CDL by requiring plans to include: key contact information at
the top of the CDL, the date of decision field, and the statement
“Please note, you will not be billed or owe any money for

We thank the commenter for the feedback that the language added
makes the CDL clearer and more understandable. We agree that
using plain language is important so that enrollees understand the
content of the CDL. The instructions that accompany the CDL state
any free text insertions should be written in a way that is
understandable by a layperson and be in plain language. We decline
to require plans attest to using plain language as we do not currently
have a mechanism to maintain the attestations, however, CMS does
review CDLs during Medicare program audits to ensure they are
understandable to enrollees.

this [insert as applicable: medical service/item or Part B drug or
Medicaid drug].”
In addition, the state Medicaid agency recommended additional
items that were not addressed in the updated CDL. These include:
changing the phrasing “service or item” to “services, supports, or
items,” adding language you must appeal to plan name by (date),
adding an online option for enrollees and allow for email
submission of appeals, specifying Medicaid drugs and over the
counter medications are in scope for the CDL, and clarifying in
the instructions document that Part B and Medicaid drugs should
be included in the CDL.

We appreciate the recommendations to strengthen the CDL by
requiring the key contact information, date of decision field, and the
note regarding not being billed for services received. States may
require the contact information and date of decision via the state
Medicaid agency contract (SMAC). The new statement added
“Please note, you will not be billed or owe any money for this [insert
as applicable: medical service/item or Part B drug or Medicaid
drug]” is a required element for post-service payment cases.
We decline updating fields to state “services, supports, or items,”
however, we have updated the CDL fields to state “medical
service/item” as this language is consistent with terms used in the
MA and MMP IDNs.
We agree and thank the commenter for the suggestion to make it
clearer where the appeal is filed. As such, we updated the CDL to
read “You must appeal to our plan by [Insert specific appeal filing
deadline date in month, date, year format – 60 calendar days from
date of letter. Insert deadline date in bold text].”
We appreciate the comment to add online and email options for
enrollees to file an appeal. Plans may allow appeals to be filed by
email, however, CMS does not have a requirement for plans to have
online options. AIPs must accept integrated appeals filed orally and
in writing.
We have added language throughout the CDL that clarifies the CDL
should also be issued for denied Medicare Part B drugs and
Medicaid drugs. The fields have been updated to allow plans to
choose the appropriate language “medical service/item or Part B
drug or Medicaid drug” based on the denial. We appreciate the
recommendation to include information in the instructions that Part
B and Medicaid drugs should be included in the CDL and have
made that update.

A health plan asked why CMS updated the term “member” to
“enrollee” throughout the CDL. In the header on page 1, it raised
concern with the contact information added under the title of the
CDL since it was confusing and drew attention away from the
CDL’s intent. The health plan also noted concern about adding the
optional field “date of decision” in the header section.
In the second paragraph, the health plan identified that disposition
‘changed’ was added, but it would not use that determination. It
also highlighted that there was a lot of information added into the
paragraph that discusses the outcome of the medical service/item.
The health plan pointed out that the information was too much to
include in one paragraph and their current process is to send a
separate approval notice for any services/items that were
approved.

We appreciate the feedback on the CDL. It was updated to use the
term ‘enrollee’ as part of a CMS-wide effort to standardize the use
of the term in materials. In the header section of the CDL, the
contact information was included so that enrollees can easily find
the contact information for the health plan. This field is optional
unless the state communicates via the SMAC that the field is
required. The ‘date of decision’ field in the header section is also an
optional field unless the state requires it via the SMAC.
In the second paragraph, plans need to chose the term that best
describes the action taken. The disposition ‘changed’ does not need
to be selected if not appropriate. The information added to this
paragraph is to give examples of language that can be utilized to
describe the outcome. Plans can use their discretion to include
language that is appropriate for the outcome in each case.

In the third paragraph, the health plan discussed the additional
information included to help clarify for the enrollee why the plan
made the decision. The health plan conveyed concerned that it
may not have the historical information needed for previously
approved services and this inclusion would make the CDL too
long.

In the third paragraph, plans should include a description of medical
service/item, including the amount, duration, and scope, of what the
enrollee requested, and the outcome. Plans should include enough
information so that the enrollee understands the full outcome of their
request.

A health plan recommended CMS allow plans to suppress or
remove fast appeal language throughout the CDL for postservice/payment cases. Fast appeal language is included in
sections titled “There are two kinds of appeals” and “How to
appeal” and they would like to be able to remove the language so
it is not confusing to enrollees.

CMS appreciates the comment but will maintain the current
language regarding fast appeals. Enrollees or their representatives
are permitted to request a fast appeal for a payment request. AIPs
should apply the same process to assess a request to expedite a
payment request as they do to assess requests to expedite nonpayment cases. The standard for deciding whether to expedite a
payment request is the same as for non-payment cases (i.e., the
standard timeframe could seriously jeopardize the life or health or
the enrollee, or their ability to regain maximum function, in
accordance with 42 CFR 422.631(c) and 422.633(e)).
Additionally, we have removed the statement “Note: You can’t get a
fast appeal if our plan denied payment for a service you already got”

from the section “There are two kinds of appeals.” This statement is
not consistent with our policy in the Addendum to the Parts C & D
Enrollee Grievances, Organization/Coverage Determinations, and
Appeals Guidance for Applicable Integrated Plans that allows
enrollees to request fast appeals for payment denials.