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.
Showing 1-10 of 51 entries
| 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 |