CMS Temporarily Eases Some Requirements for Medicare Advantage and Part D Appeals

People with Medicare who are denied coverage for a health service or item by Original Medicare, Medicare Advantage (MA), or their Part D plan may appeal—or formally request a review of—that decision.

During the coronavirus public health emergency, the Centers for Medicare & Medicaid Services (CMS) is allowing new flexibilities in how these appeals are managed. The temporary changes give the entities hearing or processing a beneficiary’s appeal the authority to remove barriers that might otherwise prevent a beneficiary from successfully filing or pursuing an appeal.

Notably, these flexibilities are optional. CMS guidance allows, but does not require, adjudicators to:

Grant an extension to file an appeal. CMS is allowing Medicare Administrative Contractors and Qualified Independent Contractors in Original Medicare, MA, and Part D plans, as well as the Part C and Part D Independent Review Entity to allow extensions to file an appeal. CMS has not yet outlined how this process would work during the emergency periods, but an extension is typically obtained by a beneficiary attaching a letter to their appeal explaining why they could not meet the deadline and requesting additional time.

Waive timeliness requests. The same entities may also waive the requirements for timeliness when they request additional information, usually from the person who is appealing. For example, typically, they may ask the appealing beneficiary to send in additional medical documents within a certain time frame, such as 15 days. Waiving the timeliness requirement would give the beneficiary more time to obtain the requested documents from their provider.

• In addition, MA plans may extend the time they have to make a decision on an appeal (excluding appeals for Part B drugs) by up to 14 calendar days if: the beneficiary requests the extension; it is justified and in the beneficiary’s interest due to the need for additional medical evidence from a noncontract provider that may change an MA organization’s decision to deny an item or service; or, the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the beneficiary’s interest.

Process appeals without appointment of representation forms. The same entities may also process an appeal even with incomplete appointment of representation forms. These forms are used by provider, advocates, and family members when they are appealing on behalf of someone else. Although the guidance allows adjudicators to process appeals without this form, they may only send follow-up communications to the appealing beneficiary.

Process requests for appeals using available information. Adjudicators may also process requests for appeals that do not meet the required elements using information that is available as outlined under current law (42 CFR §422.561 and 42 CFR §423.560). Further federal guidance is likely needed on the operationalization of this flexibility.

Utilize “good cause” flexibilities. Finally, those processing appeals may utilize the flexibilities that are available when good cause requirements are satisfied. Under current rules, beneficiaries have a limited amount of time to file an appeal. After the deadline has passed, if they can show good cause for not filing on time—such as being incapacitated—their late appeal can be considered.

The Medicare Rights Center will continue to monitor all coronavirus-related changes to the Medicare program, and will seek additional details and reforms as needed. More information about coverage during the emergency period is available on our blog post, What You Need to Know About Coronavirus and Medicare Coverage.

If you need help understanding your Medicare rights and how to exercise them, including around Medicare appeals, there is free information and assistance available. You can reach out to your local SHIP, 1-800-Medicare, and Medicare Rights’ free national helpline at 800-333-4114. 

Read more about appeals from Medicare Interactive:

Medicare Denials and Appeals

Read the guidance:

Medicare Advantage and Part D Plans: CMS Flexibilities to Fight COVID-19

COVID-19 Emergency Declaration Blanket Waivers for Health Care Providers