Notice of Denial of Medical Coverage

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Notice Testing: Notice of Denial of Medical Coverage
Dates: June-August 2024, Notice Testing Guide
Protocol (60 Minutes)
Agenda
    • Introduction (4 minutes)
    • Context Questions (5 minutes)
    • Review of notice (15-20 minutes)
    • Section-by-section review (30-35 minutes)
    • Wrap up (2 minutes)
Introduction (4 Minutes)
Thank you for joining me today. My name is [Moderator], and I work for a company called [company] in the Washington DC area. Our discussion today is part of a project sponsored by the Centers for Medicare & Medicaid Services (CMS), the agency that runs the Medicare and Medicaid programs. We are helping them to gather information to improve some of the notices that people who have Medicare might receive, and to make sure that these notices are easy to understand and use.
In a few moments, I am going to share a notice with you to read and then I’ll ask some questions about the notice, but before I do that, I’d like make sure that you are aware of a few things:
    1. Your participation today is completely voluntary. You can decide not to answer any question that we ask, and you can stop your participation at any time. Your participation or decision to stop participating will have no impact on your Medicare benefits.
    2. The information you share will be combined with information from other people, your full name will not be connected with anything you say, and your privacy will be protected.
    3. I did not create the notice we are testing, so you won’t hurt my feelings with any feedback. Also, there are no right or wrong answers. Please be open and honest with your reactions and your answers to my questions.
Informed Consent
Did you have a chance to review the consent form? Do you have any questions? Do we have your consent to participate? 
Some housekeeping items:
    1. We will be here for 60 minutes today. If you need to step away at any point, just let me know.
    2. Our discussion will be recorded so that we can make sure that we don’t miss anything that you tell us. The recording is only used for research purposes and will not be shared with anyone outside of our team.
[Begin recording]
Context Questions (5 Minutes)
Before I share the notice that we’ll be talking about, I have some questions about your Medicare coverage.
    1. Tell me about your health insurance coverage.
        a. (Probe if not mentioned) Do you have [State name for Medicaid] and Medicare?
        b. (Probe if not mentioned) Do you have a Medicare Advantage plan?
            i. What is the name of your health plan?
    2. If your doctor tells you that you need to get some kind of care – for example, if you needed a service, what would you have to do to make sure that your health insurance covers that service?
Review of the Notice (15-20 Minutes)
(Online: Show participant how to highlight and underline on shared screen, share notice on screen and give screen control. In person: Give the participant a highlighter, a pen, and a copy of the notice)
Thank you for sharing that information. Now, I’m going to give you/share a notice that you might receive from your Medicare Advantage plan. 
Imagine that your doctor or healthcare provider told you that she wants you to get a service.  Your health care provider made a request to your Medicare Advantage plan, and you receive this notice from your Medicare Advantage plan by mail. 
I would like for you to read the notice, and as you do, please use the highlighter to highlight any things that you find confusing or that you have questions about; [(in person) use the pen to circle (online) use the underline for] any things that you think are particularly important or are new information. When you are finished reading through the notice, let me know, and I’ll ask you some questions about it.
(Wait for participant to read through the notice)
First Impressions
    1. Now that you’ve read the notice, what do you think the main purpose of this notice is? 
        a. (Probe if not mentioned) What is it telling you?
        b. (Probe if not mentioned) When do you think someone might receive this notice?
    2. What is the most important information in this notice?
    3. If you received this notice, what do you think you would do next?
        a. (Probe if not mentioned) How you would do that?
    4. If you needed help or more information, what would you do?
Review of Confusing and Important Information
    1. Let’s talk through the things that you highlighted as you read:
        a. For each highlighted word/phrase: You highlighted [word/phrase]: 
            i. What is confusing about this?
            ii. What do you think this might mean?
    2. Now, let’s look at the things you circled as you read:
        a. For each circled word/phrase: You circled [word/phrase]:
            i. What makes this information important?
Section-by-Section Review (30-35 Minutes)
Now, let’s go over each section of the notice and talk about what they mean.
    1. “Your request was denied”
        a. In your own words, tell me what request was denied.
            i. According to this, who made the request?
            ii. What additional information (if any) do you think you would need to understand what request was denied?
    2. “Why did we deny your request?”
        a. In your own words, tell me why the request was denied.
            i. Do you need any additional information to understand why the request was denied?
    3. According to this notice, what should you do next? (NOTE: Notice says to share a copy of the decision with prescriber and discuss next steps)
    4. “You have the right to appeal our decision”
        a. “Plan Appeal
            i. According to this notice, what should you do if you want to appeal the decision?
                1. (Probe if not mentioned) How long do you have to ask for an appeal?
            ii. What should you do if you want to be able to continue receiving the service? 
                1. According to this notice, would you be able to do that? 
                    a. What would you need to do?
                    b. What would happen if you continued receiving the service and your appeal was denied?
        b. “If you want someone else to act for you”
            i. Who can act as your representative?
            ii. What would you need to do to have someone else be your representative?
                1. (Probe if not mentioned) Can you name a representative just by calling the phone number?
    5. “Important Information About Your Appeal Rights”
        a. “There are 2 kinds of appeals with ABC Health”
            i. What are the two kinds of appeals you can ask for?
                1. What are the differences between these two kinds of appeals?
                2. How long would it take to get a decision if you asked for a standard appeal?
                    a. What might happen that makes it take longer to get an appeal?
                3. How long would it take for you to get a decision for a fast appeal?
                    a. How would you get a fast appeal? (Probe for understanding doctor vs self-request)
        b. “How to ask for an appeal”
            i. Tell me, in your own words, how you can ask for an appeal. 
                1. (If not mentioned, probe) Do you have to personally do this?
                2. What are the ways you can send your request for appeal?
                    a. (Probe if not mentioned) Is the way you would send a request different for a standard appeal and a fast appeal?
            ii. What do you think would be “evidence” to include?
        c. “What happens next?”
            i. What happens after you ask for an appeal?
            ii. (Probe if not mentioned) Can you appeal a denial from the independent reviewer? 
Wrap Up (3 Minutes)
Thank you for sharing that great information. We are almost finished.
Now that you’ve had a chance to read the notice, and to talk about each section:
    1. How easy or difficult do you think it is to understand this notice? 
        a. What makes you say that?
    2. What could be changed to make this notice better?



PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1382 GenIC #10. This information collection is being conducted to help improve informational notices for people with Medicare and the results will be used to ensure that people with Medicare understand important information about their plans. The time required to complete this information collection is estimated to average less than 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, to review and complete the information collection. This information collection is voluntary and CMS will keep the information private to the extent provided by law. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.