1. Improvements to the Medicare Advantage Appeal and Grievance Procedures Presented by Alabama Quality Assurance Foundation 2005

2. Grijalva v. Shalala This is a 1993 class action lawsuit brought by beneficiaries enrolled in the Medicare risk-based managed care organization program. This is a 1993 class action lawsuit brought by beneficiaries enrolled in the Medicare risk-based managed care organization program. It challenged the adequacy of the managed care appeals process. It challenged the adequacy of the managed care appeals process. A settlement agreement was approved by the Arizona District Court on December 4, 2000. A settlement agreement was approved by the Arizona District Court on December 4, 2000.

3. Grijalva v. Shalala A key element of the agreement was that CMS would propose to establish an independent review entity to conduct fast- track reviews of appeals of decisions to terminate services. A key element of the agreement was that CMS would propose to establish an independent review entity to conduct fast- track reviews of appeals of decisions to terminate services. The final rule was published on April 4, 2003. The final rule was published on April 4, 2003.

4. Grijalva v. Shalala CMS determined that Quality Improvement Organizations (QIOs) will conduct these reviews because they have the necessary health care reviewers to make these medical necessity decisions. CMS determined that Quality Improvement Organizations (QIOs) will conduct these reviews because they have the necessary health care reviewers to make these medical necessity decisions. QIOs also have extensive experience with this type of review process through their similar responsibilities when Medicare beneficiaries dispute hospital discharge decisions. QIOs also have extensive experience with this type of review process through their similar responsibilities when Medicare beneficiaries dispute hospital discharge decisions.

5. Grijalva v. Shalala Effective January 1, 2004, all enrollees who are notified of their impending termination of services or discharge from a provider of service may appeal directly to an independent review entity, i.e., the Medicare QIO. Effective January 1, 2004, all enrollees who are notified of their impending termination of services or discharge from a provider of service may appeal directly to an independent review entity, i.e., the Medicare QIO.

6. Termination of Service Coverage Termination occurs when the MA organization decides to discontinue coverage of services currently being provided to an MA enrollee. Termination occurs when the MA organization decides to discontinue coverage of services currently being provided to an MA enrollee.

7. MA Enrollee’s Right All MA enrollees have the right to request a QIO fast-track review to appeal the MA organization’s decision to terminate coverage of services. All MA enrollees have the right to request a QIO fast-track review to appeal the MA organization’s decision to terminate coverage of services.

8. Settings Affected by the New Appeal Rights Home Health Agencies (HHAs) Home Health Agencies (HHAs) Skilled Nursing Facilities (SNFs) Skilled Nursing Facilities (SNFs) Comprehensive Outpatient Rehabilitation Facilities (CORFs) Comprehensive Outpatient Rehabilitation Facilities (CORFs)

9. Home Health Agency An organization that provides health care services in the home An organization that provides health care services in the home  Services such as skilled nursing care, physical therapy, occupational therapy, speech therapy, and care by home health aides –Home Health Aide services are not skilled services.

10. Skilled Nursing Facility A facility that provides skilled care services A facility that provides skilled care services  Skilled care requires the skills of qualified technical or professional health personnel such as registered nurses, licensed practical (vocational) nurses, physical therapists, occupational therapists, and speech pathologists or audiologists.

11. Skilled Nursing Facility Do not notify patients that services are not covered by Medicare because of “rules of thumb” such as lack of restoration potential, ability to walk a certain number of feet, degree of stability, or because of general inferences about patients with similar diagnoses or general data related to utilization. Do not notify patients that services are not covered by Medicare because of “rules of thumb” such as lack of restoration potential, ability to walk a certain number of feet, degree of stability, or because of general inferences about patients with similar diagnoses or general data related to utilization.

12. Skilled Nursing Facility A decision as to whether care is covered by Medicare must be made based on thorough analysis of the patient’s total condition and individual need for care. A decision as to whether care is covered by Medicare must be made based on thorough analysis of the patient’s total condition and individual need for care.

13. Comprehensive Outpatient Rehabilitation Facility A facility that provides a variety of outpatient services A facility that provides a variety of outpatient services  For example, physical therapy, social or psychological services, and rehabilitation

14. Notice of Medicare Non-Coverage Issued by the health care provider, this notice: Issued by the health care provider, this notice:  Contains the patient’s name, Medicare number, and the date services will end  Provides standardized information on a patient’s appeal rights and instructions on how to initiate an appeal, if necessary

15. Notice of Medicare Non-Coverage Prior to an MA terminating coverage of a service, the provider will be required to deliver an advance notice to the MA enrollee. Prior to an MA terminating coverage of a service, the provider will be required to deliver an advance notice to the MA enrollee.  Intent of advance notice is to inform the patient of an end date for MA coverage of the health care service being provided, allowing time for an appeal if the patient disagrees with the coverage end date.

16. Notice of Medicare Non-Coverage  Advance notice may be given as soon as the termination (effective) date is known; however, it must be given no later than two days before the proposed end of the services.  If the services are expected to be fewer than two days in duration, the patient must be notified at the time of admission.

17. Notice of Medicare Non-Coverage  Given, even if enrollee agrees that services should end.  Not to be used when the MA organization determines that an enrollee’s services should end based on the exhaustion of Medicare benefits.

18. Fast-Track Appeal The enrollee (or representative) must request a QIO Fast-Track Appeal by no later than noon the day before the effective date the Medicare coverage ends. The enrollee (or representative) must request a QIO Fast-Track Appeal by no later than noon the day before the effective date the Medicare coverage ends.  If timeline is not met, enrollee must appeal with the MA organization.

19. Fast-Track Appeal QIO will inform the MA organization and provider of the review request QIO will inform the MA organization and provider of the review request  QIO, MA organization, and provider must be available to process appeals 7 days/week and holidays, during business hours (8-4:30PM).  If valid advance notice, the QIO will instruct the MA organization to issue the detailed notice.  MA organization must submit copies of the medical record and the detailed notice to the QIO.

20. Fast-Track Appeal QIO must make a decision on an appeal and notify the enrollee, the MA organization, and the provider of services by close of business of the day after it receives the information necessary to make the decision. QIO must make a decision on an appeal and notify the enrollee, the MA organization, and the provider of services by close of business of the day after it receives the information necessary to make the decision.

21. Valid Notices Follow the Advance Notice Form Instructions, located at www.cms.hhs.gov/medicare/bni Follow the Advance Notice Form Instructions, located at www.cms.hhs.gov/medicare/bniwww.cms.hhs.gov/medicare/bni  Medicare Advantage Expedited Notices If an enrollee is not competent, the notice must be given to an authorized representative acting on behalf of the enrollee. If an enrollee is not competent, the notice must be given to an authorized representative acting on behalf of the enrollee. If an enrollee refuses to sign the notice, document that notice was given but enrollee refused to sign. If an enrollee refuses to sign the notice, document that notice was given but enrollee refused to sign.

22. Valid Delivery of Notices If the MA organization cannot personally deliver a notice to the authorized representative: If the MA organization cannot personally deliver a notice to the authorized representative:  Notify by telephone  Inform them of the contents of the notice, i.e. effective date, right to file appeal, when and how to file appeal, date that financial liability begins (day after effective date)

23. Valid Delivery of Notices Cont’d… Cont’d…  Provide QIO’s appeal # (1-800-366- 1486)  Inform them to call the QIO no later than noon the day prior to the effective date  Document telephone contact, with date/time/representative’s name  F/u by mailing the notice

24. Valid Delivery of Notices When direct telephone contact cannot be made to the authorized representative: When direct telephone contact cannot be made to the authorized representative:  Send the notice to the representative by certified mail, return receipt requested.  Date that someone at the address signs (or refuses to sign) is the date of receipt.  Document attempts to contact; include person initiating call, representative’s name, date and time of attempts, and the telephone number.

25. Valid Delivery of Notices When notices are returned by the post office, with no indication of a refusal date, the enrollee’s liability starts on the second working day after the MA organization’s mailing date. When notices are returned by the post office, with no indication of a refusal date, the enrollee’s liability starts on the second working day after the MA organization’s mailing date.  Allow enough time between the mailing date and effective date for someone to potentially respond/appeal.

26. Detailed Notices Issued by the MA organization, this notice provides the enrollee with a detailed explanation of why services are either no longer reasonable and necessary or are no longer covered. Issued by the MA organization, this notice provides the enrollee with a detailed explanation of why services are either no longer reasonable and necessary or are no longer covered.  Not given unless the patient calls the QIO for an appeal  QIO will notify MA organization to issue the detailed notice  Detailed notice due to QIO no later than close of business of day of QIO notification about the review request, or the day before the effective date, whichever is later.

27. Reconsideration If the enrollee disagrees with the QIO’s initial fast-track appeal determination, he or she may request a reconsideration. If the enrollee disagrees with the QIO’s initial fast-track appeal determination, he or she may request a reconsideration. The enrollee’s (or representative’s) request must be made no later than 60 days after the initial appeal determination. The enrollee’s (or representative’s) request must be made no later than 60 days after the initial appeal determination. The QIO will use a different physician reviewer and complete the review within 14 calendar days from the date of the reconsideration request. The QIO will use a different physician reviewer and complete the review within 14 calendar days from the date of the reconsideration request.

28. Administrative Law Judge (ALJ) Review Request If the enrollee disagrees with the QIO’s reconsideration determination, he or she may request an ALJ appeal. If the enrollee disagrees with the QIO’s reconsideration determination, he or she may request an ALJ appeal. The enrollee (or representative) must request an ALJ appeal within 60 days from the date of the QIO’s reconsideration determination. The enrollee (or representative) must request an ALJ appeal within 60 days from the date of the QIO’s reconsideration determination. The QIO must prepare and forward the case to the ALJ within 30 days of receipt of the appeal request. The QIO must prepare and forward the case to the ALJ within 30 days of receipt of the appeal request.

29. Responsibilities MA Organization MA Organization  Determines discharge date and provides detailed notice, upon request (unless delegated to their contracting providers)

30. Responsibilities Provider Provider  Delivers the advance notice, Notice of Medicare Non-Coverage (NOMNC), to all enrollees no later than 2 days before their covered services end (effective date)

31. Responsibilities Patient/MA enrollee (or authorized representative) Patient/MA enrollee (or authorized representative)  Acknowledges receipt of the NOMNC and contacts the QIO (within specified timelines) if they wish to obtain an expedited review

32. Responsibilities QIO QIO  Immediately contacts the MA organization and the provider if enrollee requests an expedited review  Makes decision on the case by no later than the day Medicare coverage is predicted to end (generally within 48 hours of enrollee’s review request)

33. Grijalva Regulations Provide an appeal process for MA termination of services decisions. Provide an appeal process for MA termination of services decisions. When possible, limit the financial liability to the MA enrollee while the appeal is being considered. When possible, limit the financial liability to the MA enrollee while the appeal is being considered.

34. MA Appeals Number AQAF’s Appeals #: AQAF’s Appeals #:  1-800-366-1486  Insert this number on the notice

35. AQAF Contacts 1-800-760-4550 Pam Taylor, Beneficiary Protection Program Manager, ext. 3512 Pam Taylor, Beneficiary Protection Program Manager, ext. 3512 Barbara Baites, Review Coordinator, ext. 3228 Barbara Baites, Review Coordinator, ext. 3228 Anita Meyers, Review Coordinator, ext. 3217 Anita Meyers, Review Coordinator, ext. 3217 Laura Rutledge, Review Coordinator, ext. 3429 Laura Rutledge, Review Coordinator, ext. 3429 Cathy Dixon, Review Coordinator, ext. 3426 Cathy Dixon, Review Coordinator, ext. 3426

36. Questions????

37. Alabama Quality Assurance Foundation This material was prepared by Alabama Quality Assurance Foundation (AQAF), the Medicare Quality Improvement Organization for Alabama under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health & Human Services. The contents presented do not necessarily reflect CMS policy. 8SOW-AL-GEN-05-23