HCFA Proposes New Rules for Medicare+Choice Enrollees
Managed care organizations that participate in the Medicare+Choice program would have to provide enrollees with "advance notice of termination" of certain pre-authorized health services, a "fast-track process for appealing such decisions," and other protections under new rules proposed yesterday by HCFA. The proposed regulations stem from a court settlement -- signed in August and approved in December -- in the case of Grijalva v. Shalala, a 1993 class-action suit brought against HHS in which lawyers working on behalf of Medicare+Choice enrolles argued that the managed care appeals process was inadequate and that the agency had "failed to enforce enrollees' appeals process rights when contractors denied, reduced or terminated their health coverage." The following are the main provisions of the proposed rule:
- Medicare+Choice organizations would have to give enrollees "four days written notice before terminating pre-authorized care from a home health agency, skilled nursing home facility or comprehensive outpatient rehabilitation facilities."
- Advance notices of care termination would have to include a "detailed explanation" of why the treatment was denied and information on how the patient can appeal the decision to deny care to a "designated fast track Independent Review Entity (IRE) under contract to HCFA."
- If the enrollee appeals, coverage from the Medicare+Choice managed care organization would have to continue until at least the day after the decision by the IRE, or the date and time "specified in the notice of termination" by the organization, whichever is later.
- In an appeal, the "burden" would rest with the organization "to support its decision to deny coverage."
- The IRE would have to "solicit the enrollee's ... views before making a final decision," and the enrollee could request a copy of his or her case files, or other documentation that the organization sent to the IRE.
- Finally, "[r]egardless of the IRE decision," coverage would continue "if it is determined that" the organization "did not provide proper and full notice of termination of health care coverage" as outlined in these rules.
The proposed rules were published today in the Federal Register. HCFA invites public comment, which they must consider in the development of the final rule. As of January 1, approximately 1 million of the 6.2 million Medicare beneficiaries participating in the Medicare+Choice program, which was established as part of the 1997 Balanced Budget Act, were dropped by their managed care organization. These beneficiaries either had to enroll in another managed care organization or in Medicare fee for service (HCFA release, 1/23). This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.