Appeal Rights for Medicare Advantage Program Enrollees

Background Information on Appeals

Medicare Advantage (formerly Medicare + Choice) refers to health plans that contract with Medicare to provide managed health care services to their enrollees and are reimbursed by Medicare.

Beneficiaries enrolled in Medicare Advantage plans already have the ability to request a fast track appeal of their health plan's decision to terminate continued coverage of services by hospitals for in-patient stays.

Appeal rights (available since January 1, 2004) provide beneficiaries with fast track appeal rights for potential denial of care and services provided by Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs) or Comprehensive Outpatient Rehabilitation Facilities (CORFs).

Quality Improvement Organizations like IPRO in New York have been designated as Independent Review Entities (IREs) to respond to consumer appeals about termination of services in Home Health Agencies, Skilled Nursing Facilities or Comprehensive Outpatient Rehabilitation Facilities.

What does this mean?

Access to the Appeals Process

• Beneficiaries now have the right to an immediate, independent Medicare review (appeal) of a health plan's decision to end services in settings other than hospitals, i.e., Home Health Agencies, Skilled Nursing Facilities and Comprehensive Outpatient Rehabilitation Facilities.
• Beneficiaries or their representatives must receive a form called a Notice of Medicare Non-Coverage (NMNC) from the health care provider before services can be terminated.

This notice tells you when your services will end and describes your right to appeal the decision of your Medicare Advantage plan to discontinue services you are receiving in a Skilled Nursing Facility (SNF), Home Health Agency (HHA) or Comprehensive Outpatient Rehabilitation Facility (CORF).

The notice tells you how to ask for an immediate or fast track appeal. Timing is important. You or your designated representative should call IPRO, New York's Independent Review Entity (IRE), no later than noon of the day before the effective date on the notice. IPRO's toll free number for Skilled Nursing Facility, Home Health Agency or Comprehensive Outpatient Rehabilitation Facility fast track appeals is 888-696-9561. This number is available seven days a week between 8:30 am and 4:30 pm, including Saturday and Sunday.

The Notice of Medicare Non-Coverage also tells you about other appeal rights available through your Medicare Advantage plan if you miss the above deadline.

The DENC notice explains why your plan feels that the services you are receiving may no longer be considered medically necessary or may not be covered under Medicare.

If you choose to appeal, the independent reviewer (IPRO in New York) will ask for your opinion about why services should not be discontinued. You do not have to prepare anything in writing but you may if you wish. You will be able to get a quick review of the plan's decision with independent (IPRO) doctors looking at your case and deciding if your services need to continue.

IPRO will notify you or your representative by telephone and in writing most often by the close of business the day after all the medical record information is received. It is important to ask about additional appeal rights if your first appeal is not successful.

• If the independent reviewer agrees with your health plan, neither Medicare or your health plan will pay for the health care services after the date on the notice.
• If you stop services before the date listed on the form you will avoid financial liability (paying for services not considered medically necessary).

Medicare Advantage Enrollee Rights and Hospital Care

• All beneficiaries admitted to a Medicare participating hospital should be given a copy of the "Important Message from Medicare" at or around the time of admission. This notice explains the right to appeal decisions about a continued stay in the hospital.
• If you are a Medicare Advantage enrollee and receive a notice called "Notice of Discharge and Medicare Appeal Rights" and you do not feel ready for discharge, discuss the matter with your doctor, follow the instructions on the form and file an appeal. If you are told about your discharge and you do not agree, ask for the notice in writing if it has not been provided.
• The Notice of Discharge and Medicare Appeal Rights explains why you are being discharged, how to get a fast review, time frames to follow for an appeal and what you may have to pay if you choose to remain in the hospital after the date listed on the notice. You may be able to stay in the hospital at no charge while IPRO (the Independent Review Entity) reviews your case. Fast reviews are most often completed within 72 hours from filing.

Resources

For additional information about inpatient hospital appeals please call:

• 1-800-Medicare (1-800-633-4227) 24 hours/7 days a week or visit www.Medicare.gov, TTY users should call 1-877-486-2048
• IPRO Helpline/Inpatient Hospital Appeals 1-800-331-7767
• Skilled Nursing Facility, Home Health Agency and Comprehensive Outpatient Rehabilitation Facility Fast Track Appeals 1-888-696-9561
• Also call your Medicare Advantage Plan with questions.
• New York State Health Insurance Counseling and Assistance Program (HIICAP) 1-800-333-4114

This material was prepared by IPRO under a contract with the Centers for Medicare & Medicaid Services (CMS). The contents do not necessarily reflect CMS policy.