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Medicare Managed Care Appeals & Grievances

Important News for Beneficiaries: Jimmo Re-Review Information

Background
On January 24, 2013, the U.S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius (Jimmo).  As part of the Jimmo settlement agreement, Medicare clarified that maintenance coverage under the skilled nursing facility (SNF) and home health (HH) benefits, and skilled therapy under the SNF, HH, and outpatient therapy (OPT) benefits does not depend on whether the patient can improve, but on whether skilled care is required and whether the services themselves are reasonable and necessary.  The Jimmo vs. Sebelius case fact sheet is available online at http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/Downloads/Jimmo-FactSheet.pdf).   

Re-review of Denied Claims
The Jimmo settlement agreement also provides for the re-review of certain Medicare claims under clarified maintenance coverage standards for the SNF, HH, and OPT benefits, applicable when a patient has no restoration or improvement potential, but that patient requires skilled SNF, HH, or OPT services to maintain, or to prevent or slow further deterioration of, his or her clinical condition.  

Beneficiaries, please click on the link below to access the proper form for requesting a re-review of your claim pertaining to the Jimmo settlement:

Request for Re-Review of Medicare Claims Related to the Settlement Agreement in Jimmo V. Sebelius

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Medicare Managed Care Appeals & Grievances

Medicare health plans, which include Medicare Advantage (MA) plans – such as Health Maintenance Organizations, Preferred Provider Organizations, Medical Savings Account plans and Private Fee-For-Service plans – Cost Plans and Health Care Prepayment Plans, must meet the requirements for grievance and appeals processing under Subpart M of the Medicare Advantage regulations.  For a detailed discussion of the Medicare managed care grievance and appeals processes, click on the link below to "Chapter 13 - Medicare Managed Care Manual" under "Downloads."

If a Medicare health plan denies service or payment, in whole or in part, the plan is required to provide the enrollee with a written notice of its determination.  Additionally, Medicare health plan enrollees receiving covered services from an inpatient hospital, skilled nursing facility, home health agency, or comprehensive outpatient rehabilitation facility have the right to a fast, or expedited, review if they think their Medicare-covered services are ending too soon.  Plans and providers have certain responsibilities related to notifying beneficiaries of Medicare appeal rights.  

For additional information concerning Medicare managed care appeals notice requirements, including Spanish versions of the notices, click on the links in the "Related Links" below.  

WEB BASED TRAINING COURSE AVAILABLE FOR PART C

The course covers requirements for Part C organization determinations, appeals, and grievances found at 42 CFR Part 422, Subpart M and Chapter 13 of the Medicare Managed Care Manual. Complete details are listed on the "Guidance" page (select "Guidance" link on the navigation menu found at the left side of this page).