Center Comments on CMS-10003 Notice of Denial of Medical Coverage (or Payment)

• Rationale for recommended change

  • This change to the NDMPC would make it consistent with the Notice of Medicare Non-Coverage which gives the effective date coverage of current services will end. 

2.  Comments regarding the section entitled You have the right to appeal our decision

• Recommended change #1

  • The revised NDMPC should include the date by which an appeal must be made.  For example, “Ask {health plan name} for an appeal within 60 days [Insert State Medicaid timeframe for internal plan appeals, if different] of the date of this notice.  We must receive your appeal by: [Insert date when an appeal must be received].”

• Rationale for recommended change #1

  • The Medicare Summary Notice (MSN) used for those who are in the traditional Medicare program includes a date in a box when an appeal must be received.  Although the appeal tracks for traditional Medicare and Medicare Part C differ, the MSN serves the same purpose as the NDMPC, which is to give Medicare beneficiaries information in a meaningful and understandable way.  People who are receiving a NDMPC may be in a health care crisis and including this information, in the same way as the MSN, ensures that there is no misunderstanding regarding the deadline for an appeal.

• Recommended change #2

  • The NDMPC states that “[w]e can give you more time if you have a good reason for missing the deadline.”  This language is misleading. The NDMPC should be revised to state: “It is important that you appeal the decision within the 60-day period.  If, however, you miss the 60-day period in which to file an appeal you may request an extension of the timeframe.  The request for reconsideration and the request for an extension of the timeframe must be in writing and must clearly state why the request for reconsideration was not filed on time.  It is within the plan’s discretion to accept or deny the request for an extension.”   

• Rational for recommended change #2

• 42 CFR §422.582 allows an extension of the timeframe for filing a request for reconsideration if the enrollee can show good cause for the delay.  The request must be in writing and must state the reason why the request was not filed on time.  The current NDMPC does not instruct enrollees to send their request for an extension in writing.  In addition, it is our experience that enrollees who receive this NDMPC are often experiencing a health care crisis, often miss the deadline for filing an appeal, and thus, need an extension to file an appeal.  It is also our experience that when an enrollee does appeal and requests an extension, the health plan often denies the request.  The importance of appealing within 60 days and the fact that an extension of time to appeal is not guaranteed should be underscored. 

3. Comments regarding the section entitled Important Information About Your Appeal Rights

• Recommended change #1

  • Instead of calling it a Fast Appeal, the NDMPC should refer to an Expedited or Fast Appeal.

• Rationale for recommended change #1

  • The Medicare regulations as well as the Medicare Managed Care Manual refer to this type of appeal as an “Expedited” appeal request.  Keeping the language used in Medicare regulations, Manual provisions and the NDMPC consistent would help to minimize any potential confusion.

• Recommended change #2

  • The NDMPC should make it clear that a Part C Medicare organization will expedite a request for appeal that involves specific issues including:

• The Part C organization’s refusal to provide or pay for services, in whole or in part, including the type or level of services, that the enrollee believes should be furnished or arranged for by the Part C organization; and

• Reduction, or premature discontinuation of a previously authorized ongoing course of treatment.

• In addition, the NDMPC should state in the description of an expedited appeal that a Part C Medicare organization will not expedite an appeal request for payment of services already furnished.

• Rationale for recommended change #2

  • 42 CFR §422.584(a) only allows expedited appeals for certain issues.  The description of a standard appeals says that if an appeal is for payment of a service already received, a decision will be given within 60 days.  However the description of a “Fast Appeal” makes it sound like an enrollee will automatically get a fast appeal if the doctor asks for one or supports a request regardless of what type of appeal it is.

4. Comments regarding the section entitled How to ask for an appeal {health plan name}

• Recommended change

  • The NDMPC should include a model form for enrollees to use when filing an appeal. 

• Rationale for recommended change

  • Those who have traditional Medicare, rather than a Part C Medicare plan, are given appeal forms at every stage of the appeals process.  The redesigned Medicare Summary Notice has a form on the last page of the notice with step-by-step directions on how to fill out the form and request a redetermination decision.  The redetermination decision includes a Reconsideration Request Form that an individual can use to request an appeal to the next level.  The reconsideration decision includes a link to a form to be used when requesting an Administrative Law Judge hearing.

Often times those who receive notices regarding their health care are in crisis and including a form to use when appealing will ensure all required information is included with an appeal.  Also an appeal form is more likely to be noticed by a Part C Medicare organization as an appeal, rather than a grievance or a complaint, which are handled and processed differently.

If you have any questions regarding the Center for Medicare Advocacy’s comments on the revisions to CMS-10003 Notice of Denial of Medical Coverage (or Payment), please contact me.

Sincerely,

/s/ Mary Ashkar

Mary Ashkar
Senior Attorney
Center for Medicare Advocacy