Important New Medicare Part C and D Appeal Rights

Some important changes in appeal rights for Medicare beneficiaries who are in Medicare Advantage (managed care) or in Part D of Medicare go into effect on January 1, 2011. (Because Medicare's contracts with Part C and Part D companies are on a calendar year basis, changes typically occur at the begining of each year.) These changes are:

Part C

2011 brings a substantial expansion in the appeal rights of beneficiaries enrolled in managed care. Specifically, whenever any written plan of care, course of treatment, or arrangement for medical services is drawn up for you, your Plan must give you a written notice before it discontinues the services, or reduces their number, or lowers the intensity of the treatment, or changes the mix or range of sessions or services. You can then make a request for an organization determination to reverse this. This, of course, does not in any way affect your right to request such a determination at any time, it just puts the burden of a prior, written notice on the Plan in these cases and reinforces your right to appeal. Previously, beneficiaries had this right only in four specific provider settings (see page 200 of Managing Your Medicare).

Another expansion is that beneficiaries now have the right to make a request for an organization determination orally, and Plans must have a method to properly record and control these. (This does not apply to request for payment for a service already rendered.)


Part D

Beneficiaries now have the right to make a request for a coverage determination orally, and drug plans must have a method to properly record and control these. (This does not apply to request for payment for a drug already received by the beneficiary.)

If a request for a coverage determination for payment for a drug already received is made, the plan must make a decision in 14 (not three) days, and actually make payment, if any is due, within those 14 days.

In Part D, a plan may now give their response to either a fully favorable or to an adverse expedited coverage determination orally, as long as they follow up with a written notice in three days. And the appeals clock starts from the date of the written notice. This also applies to expedited redetermination requests. In either case, if there are conditions which attach to a fully favorable expedited determination or redetermination, the notice must state them in a “readable and understandable form.”