CMS issues final rule on appeal rights for applicable plans

The Centers for Medicare & Medicaid Services (CMS) issued a final rule last week regarding the formal appeals process for applicable plans in situations where the agency seeks Medicare Secondary Payer (MSP) recovery from an applicable plan. The rule is effective April 28.

The final rule laid out the multi-level appeal process, which begins with an initial determination in the form of the MSP recovery demand letter--including a specific timeframe to proceed to the next level of appeal--and ends with a judicial review.

CMS constituted applicable plans as liability insurance, which includes self-insurance, as well as no-fault insurance and workers' compensation laws or plans. Only applicable plans can appeal when Medicare seeks out recovery directly from said plan. While beneficiaries are not involved in the appeals process, CMS must notify them if their plan files a request.

When it comes to requesting an appeal, applicable plans must provide proper proof of presentation. Those without presentation will be dismissed.

Finally, CMS detailed what applicable plans can and cannot appeal. The amount of the debt and/or the existence of the debt is fair game, but plans are not able to appeal the issue of who is the correct debtor.

This recent final rule comes on the heels of the Strengthening Medicare and Repaying Taxpayers Act of 2012's latest provision, which ensures that Medicare beneficiaries who receive coverage are notified if their plan intends to appeal.

For more:
- here's the fact sheet (.pdf)