Medicare Advantage & Prescription Drug Plan Appeals
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 access questions, please contact the OH CDMS Help Desk at 1-833-783-8255 or Helpdesk_OHCDMS@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.
| Decision Number | Case Name | Topic or Issue |
|---|---|---|
Sonder Health Plans, Inc.
|
Network Deficiency (Administrator declined review)
|
|
Longevity Health Plan of North Carolina, Inc.
|
Network Deficiency; Exception Request (with Administrator's Review)
|
|
Longevity Health Plan of Michigan, Inc.
|
Network Deficiency; Exception Request (with Administrator's Review)
|
|
Molina Healthcare of Nebraska, Inc.
|
Past Performance; Network Deficiency (Administrator declined review)
|
|
Molina Healthcare of Indiana, Inc.
|
Past Performance; Network Deficiency (Administrator declined review)
|
|
Zing Health, Inc.
|
Licensure; Past Performance; Star Ratings; Letters of Intent (Administrator declined review)
|
|
Lasso Healthcare Insurance Company
|
Past Performance; Star Ratings (Administrator declined review)
|
|
Provider Partners Health Plan of North Carolina
|
Letters of Intent (no request for Administrator review)
|
|
HealthSpring Life & Health Insurance
|
Novation; Exception Requests; Network Deficiency; Letters of Intent (no request for Administrator review)
|
|
VNS Choice Health Plan
|
Network Deficiency; Letters of Intent (no request for Administrator review)
|
|
Chinese Community Health Plan
|
Network Deficiency (Administrator declined review)
|
|
Verda Health Plan of Texas, Inc.
|
Licensure; Network Deficiency (Administrator declined review)
|
|
Imperial Health Plan of California
|
Contract Termination; Star Ratings (Administrator declined review)
|
|
Vitality Health Plan of California
|
Past Performance
|
|
Reliance HMO, Inc.
|
Past Performance
|
|
Renal Payer Solutions, Inc.
|
Licensure
|
|
Leon Health Plans, Inc.
|
Contracting
|
|
eternalHealth, Inc.
|
Contracting (with Administrator's Review)
|
|
Community Insurance Company
|
Contracting
|
|
Essence Healthcare, Inc.
|
Licensure (with Administrator's Review)
|
|
Exemplar Health Insurance Company, Inc.
|
Licensure/Waiver Applications
|
|
Centene Venture Company
|
Agency adherence to deficiency notification requirements; definition and documentation of relationships with first tier, downstream and related entities; adequacy of contract payment terms.
|
|
Meridian Health Plan of Michigan
|
Definition and documentation of relationships with first tier, downstream and related entities; consideration of materials received after the deadline of final submission of application.
|
|
Constellation Health, LLC
|
Termination - Authorized Official Lack of Standing
|
|
Provider Partners Health Plan of Missouri, Inc.
|
Contracting
|
|
Prominence Health First of Florida, Inc.
|
Licensure
|
|
Texas Independence Health Plan, Inc.
|
Failure to File Timely Application
|
|
Anthem, Inc.
|
Past Performance
|
|
Constellation Health, LLC
|
State Licensure
|
|
HealthSpring Life and Health Insurance Company
|
Two Year Contracting Prohibition - Non-Renewal
|
|
Legacy Health Plan, Inc.
|
State Licensure
|
|
Bright Health Insurance Company of New York, Inc.
|
State Licensure
|
|
Longevity Health Plan of New Jersey Insurance Company, Inc.
|
Application - Legal Entity
|
|
Golden Cross Health Plan Corp.
|
Jurisdiction/Nullification
|
|
Blue Cross and Blue Shield of Michigan
|
Failure to meet health services management and delivery application requirement.
|
|
Health Advantage Florida, Inc.
|
Lack of Appropriate State License.
|
|
Universal Care, Inc.
|
Failure to Provide State Approval for d/b/a.
|
|
Bright Health Company of New York, Inc.
|
Lack of Appropriate State Licensure.
|
|
Anthem - BCBSA of California
|
Adequacy of network; application process.
|
|
Viventum Health Plan
|
State licensure.
|
|
Boston Medical Center Health Plan
|
Denial of service area expansion on basis that Applicant lacked 14 months of performance history.
|
|
United Health Group, Inc. UHC of California
|
Adequacy of network; application process.
|
|
Eden Health Plan
|
State licensure; fiscal solvency.
|
|
Sanford Heart of America Health Plan
|
Adequacy of network.
|
|
Provider Partners Health Plan
|
Adequacy of network.
|
|
WellCare Health Plans of New Jersey, Inc. - Denial of Initial Application, H1587
|
Assessment of Negative Performance Points
|
|
Harvard Pilgrim Health Care, Inc. (HPHC)
|
Denial of service area expansion on basis that Applicant lacked 14 months performance history.
|
|
Arkansas Superior Select, Inc. - Denial of Initial Application, H1587
|
Application Process
|
|
MedStar Family Choice, Inc. SAE and SNP – Denial of Application H9915
|
Duration of sponsor performance history; plan product offerings; impact of erroneous conditional approval on final outcome; materiality of disputed facts.
|
|
University Care Advantage, LLC – Denial of Application H7352
|
Adequacy of network; consistency of CMS exception process with the regulations; consideration of materials received after the deadline of final submission of application.
|
|
Community Care Alliance of Illinois ? Denial of Application H3071
|
Lack of appropriate state licensure at time of application; consideration of materials received after the deadline of final submission of application.
|
|
Gateway Health Plan of Ohio, Inc. – Denial of Application H9190
|
Agency adherence to deficiency notification requirements; definition and documentation of relationships with first tier, downstream and related entities.
|
|
Blue Cross Blue Shield of Montana, Inc. – Denial of Application H0107
|
Agency adherence to deficiency notification requirements; definition and documentation of relationships with first tier, downstream and related entities; adequacy of contract payment terms.
|
|
Moda Health Plan, Inc. – Denial of Application H1307
|
Adequacy of network; consistency of CMS exception process with the regulations; consideration of materials received after the deadline of final submission of application.
|
|
Vantage Health Plan of Arkansas, Inc. – Denial of Application H6380
|
Definition and documentation of relationships with first tier, downstream and related entities; consideration of materials received after the deadline of final submission of application.
|
|
United Healthcare Insurance Company Service Area Expansions and Initial Denials
|
Denial of service area expansions and initial applications due to failure to comply with terms of a current or previous year's contract.
|
|
Senior Whole Health, LLC Denial of Service Area Expansion
|
Lack of appropriate state licensure
|
|
Fox Insurance Company - Immediate Termination of Prescription Drug Plan,
|
Proof of imminent and serious risk to health; necessity to prove financial difficulties for immediate termination; date of substantial compliance under the regulation.
|
|
Guardian Healthcare, Inc. - Denial of Applications H7341 & H9779
|
Adequacy of network, consistency of CMS exception process with the regulations; failure to consider materials received after the deadline of final submission of application; failure to provide evidence of fiscal solvency.
|
|
Universal Health Insurance Company, Inc. - Denial of Initial Applications, H8098 and H8319
|
Failure to complete correctly (adequacy of network concern travel distance and time to various providers); adequacy of CMS intent to deny notices; authority of Hearing Officer to sever service areas.
|
|
Stonebridge Life Insurance Company, Inc. - Denial of Initial Application, S3502
|
Failure to include various contract provisions in all plan's contracts with first tier, downstream and related entities.
|
|
Piedmont Community HealthCare, Inc. - Denial of Initial Application, H1659
|
Adequacy of network concerning dialysis services; no exceptions for provider's refusal to contract.
|
|
Arkansas Blue Cross and Blue Shield - Denial of Initial Application, H8091
|
Adequacy of contract language concerning production of records by the plan or its contractors to CMS or other government entities.
|
|
Citrus Health Care - Denial of Service Area Expansion Contract # H5407
|
Use of Star Rating System to deny applications for fiscal year 2011.
|
|
American Health Alliance, Inc. - Denial of Initial Application, H6037
|
Failure to make attestation; failure to complete application correctly (clearly define relationships between first tier, downstream and related entities).
|
|
Arcadian Health Care Plan, Inc. - Service Area Expansion Application Denials, H4529, H5783 and H6497
|
Failure to submit proper documentation of its network access as required.
|
|
Red Medica de Puerto Rico, Inc. - Initial Application Denial, H3420
|
Noncompliance with the MA-PD program.
|
Page Last Modified:
09/10/2024 06:23 PM