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 /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
Page Last Modified:
06/22/2022 12:10 PM