Medicare Advantage & Prescription Drug Plan Appeals

Medicare Advantage ("MA") and Prescription Drug ("PD") Plans are permitted to participate in the Medicare Program under Sections 1857 and 1860D-12 of the Social Security Act and regulations at 42 C.F.R. §§ 422.500 and 423.500 et seq. If the Centers for Medicare & Medicaid Services ("CMS") denies an application to qualify as an MA or PD Plan or takes adverse action (termination, non-renewal, intermediate sanction) against an existing MA or PD Plan, the applicant or existing MA or PD Plan is entitled to request a hearing before a CMS Hearing Officer. 42 C.F.R. §§ 422.660 and 423.650 et seq.

Electronic Filing Required

Beginning in May 2022, the Hearing Officer requires appeals for MA/PD Plans to be filed electronically through the Office of Hearings Case and Document Management System (“OH CDMS”). Reference Hearing Officer Electronic Filing for registration instructions and the system user manual.

For any system or registration questions, contact the OH CDMS Help Desk at 1-833-783-8255 or Helpdesk_OHCDMS@cms.hhs.gov.

For general non-system questions, please direct your inquires to the Office of Hearings via e-mail at HearingOfficer@cms.hhs.gov.

Listing of MA/PD Contract Determination Decisions

The CMS Hearing Officer's decisions may be reviewed by the CMS Administrator in accordance with 42 C.F.R. §§ 423.666 and 422.690. Below is a list of selected decisions for MA/PD cases.

Showing 1 – 10 of 67 entries

Show Entries

Filter On

Decision Number	Case Name	Topic or Issue
Decision Number 2023 H-23-00022	Case Name Sonder Health Plans, Inc.	Topic or Issue Network Deficiency (Administrator declined review)
Decision Number 2023 H-23-00019 and Administrator's Review	Case Name Longevity Health Plan of North Carolina, Inc.	Topic or Issue Network Deficiency; Exception Request (with Administrator's Review)
Decision Number 2023 H-23-00018 and Administrator's Review	Case Name Longevity Health Plan of Michigan, Inc.	Topic or Issue Network Deficiency; Exception Request (with Administrator's Review)
Decision Number 2023 H-23-00017	Case Name Molina Healthcare of Nebraska, Inc.	Topic or Issue Past Performance; Network Deficiency (Administrator declined review)
Decision Number 2023 H-23-00016	Case Name Molina Healthcare of Indiana, Inc.	Topic or Issue Past Performance; Network Deficiency (Administrator declined review)
Decision Number 2023 H-23-00012	Case Name Zing Health, Inc.	Topic or Issue Licensure; Past Performance; Star Ratings; Letters of Intent (Administrator declined review)
Decision Number 2023 H-23-00011	Case Name Lasso Healthcare Insurance Company	Topic or Issue Past Performance; Star Ratings (Administrator declined review)
Decision Number 2023 H-23-00008	Case Name Provider Partners Health Plan of North Carolina	Topic or Issue Letters of Intent (no request for Administrator review)
Decision Number 2023 H-23-00007	Case Name HealthSpring Life & Health Insurance	Topic or Issue Novation; Exception Requests; Network Deficiency; Letters of Intent (no request for Administrator review)
Decision Number 2023 H-23-00005	Case Name VNS Choice Health Plan	Topic or Issue Network Deficiency; Letters of Intent (no request for Administrator review)

1 2 3 4 5 6 7