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 /regulations-guidance/cms-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 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|
|2021 H-21-0015||Leon Health Plans, Inc.||Contracting|
|2021 H-21-0013 and H-21-0014 and Administrator's Review||eternalHealth, Inc.||Contracting (with Administrator's Review)|
|2021 H-21-0011||Community Insurance Company||Contracting|
|2021 H-21-0009 and Administrator's Review||Essence Healthcare, Inc.||Licensure (with Administrator's Review)|
|2021 H-21-0006||Exemplar Health Insurance Company, Inc.||Licensure/Waiver Applications|
|2020 MAPD App. 15-21||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.|
|2020 MAPD App. 09||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.|
|2019 MAPD App. 08||Constellation Health, LLC||Termination - Authorized Official Lack of Standing|
|2019 MAPD App. 07||Provider Partners Health Plan of Missouri, Inc.||Contracting|
|2019 MAPD App. 05||Prominence Health First of Florida, Inc.||Licensure|