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List of MA/PD Decisions

List of selected CMS Hearing Officer decisions on Medicare Advantage / Prescription Drug Plan cases.

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Decision Number Case Name Topic or Issue
2010 CD App. 02 Citrus Health Care - Denial of Service Area Expansion Contract # H5407 Use of Star Rating System to deny applications for fiscal year 2011.
2010 CD App. 01 and Administrator's Review American Health Alliance, Inc. - Denial of Initial Application, H6037 Failure to make attestation; failure to complete application correctly (clearly define relationships between first tier, downstream and related entities).
2010 CD App. 06 Piedmont Community HealthCare, Inc. - Denial of Initial Application, H1659 Adequacy of network concerning dialysis services; no exceptions for provider's refusal to contract.
2010 CD App. 03 Arkansas Blue Cross and Blue Shield - Denial of Initial Application, H8091 Adequacy of contract language concerning production of records by the plan or its contractors to CMS or other government entities.
2010 CD App. 07 Stonebridge Life Insurance Company, Inc. - Denial of Initial Application, S3502 Failure to include various contract provisions in all plan's contracts with first tier, downstream and related entities.
2010 CD Apps. 11 and 12 Universal Health Insurance Company, Inc. - Denial of Initial Applications, H8098 and H8319 Failure to complete correctly (adequacy of network concern travel distance and time to various providers); adequacy of CMS intent to deny notices; authority of Hearing Officer to sever service areas.
2010 CD Apps. 13 and 14 Guardian Healthcare, Inc. - Denial of Applications H7341 & H9779 Adequacy of network, consistency of CMS exception process with the regulations; failure to consider materials received after the deadline of final submission of application; failure to provide evidence of fiscal solvency.
2010 CD Term 01 Fox Insurance Company - Immediate Termination of Prescription Drug Plan, Proof of imminent and serious risk to health; necessity to prove financial difficulties for immediate termination; date of substantial compliance under the regulation.
2011 CD Apps. 01 thru 10 with Administrator's Review United Healthcare Insurance Company Service Area Expansions and Initial Denials Denial of service area expansions and initial applications due to failure to comply with terms of a current or previous year's contract.
2011 CD App. 12 with Administrator's Review Senior Whole Health, LLC Denial of Service Area Expansion Lack of appropriate state licensure
2013 MA/PD App. 02 Vantage Health Plan of Arkansas, Inc. – Denial of Application H6380 Definition and documentation of relationships with first tier, downstream and related entities; consideration of materials received after the deadline of final submission of application.
2013 MA/PD App. 03 Moda Health Plan, Inc. – Denial of Application H1307 Adequacy of network; consistency of CMS exception process with the regulations; consideration of materials received after the deadline of final submission of application.
2013 MA/PD App. 05 with Administrator's Review Blue Cross Blue Shield of Montana, Inc. – Denial of Application H0107 Agency adherence to deficiency notification requirements; definition and documentation of relationships with first tier, downstream and related entities; adequacy of contract payment terms.
2013 MA/PD App. 06 Gateway Health Plan of Ohio, Inc. – Denial of Application H9190 Agency adherence to deficiency notification requirements; definition and documentation of relationships with first tier, downstream and related entities.
2013 MA/PD App. 07 with Administrator's Review Community Care Alliance of Illinois – Denial of Application H3071 Lack of appropriate state licensure at time of application; consideration of materials received after the deadline of final submission of application.
2013 MA/PD Apps. 08 and 11 with Administrator's Review MedStar Family Choice, Inc. SAE and SNP – Denial of Application H9915 Duration of sponsor performance history; plan product offerings; impact of erroneous conditional approval on final outcome; materiality of disputed facts.
2013 MA/PD App. 10 University Care Advantage, LLC – Denial of Application H7352 Adequacy of network; consistency of CMS exception process with the regulations; consideration of materials received after the deadline of final submission of application.
2014 MA/PD App. 02 Arkansas Superior Select, Inc. - Denial of Initial Application, H1587 Application Process
2014 MA/PD Apps. 06 and 07 with Administrator's Review Harvard Pilgrim Health Care, Inc. (HPHC) Denial of service area expansion on basis that Applicant lacked 14 months performance history.
2014 MA/PD Apps. 10 and 11 WellCare Health Plans of New Jersey, Inc. - Denial of Initial Application, H1587 Assessment of Negative Performance Points
2008 CD App. 01 Red Medica de Puerto Rico, Inc. - Initial Application Denial, H3420 Noncompliance with the MA-PD program.
2008 CD Apps. 04, 05 and 07 Arcadian Health Care Plan, Inc. - Service Area Expansion Application Denials, H4529, H5783 and H6497 Failure to submit proper documentation of its network access as required.
2015 MA/PD App. 01 and Administrator's Review Provider Partners Health Plan Adequacy of network.
2015 MA/PD App. 03 and Administrator's Review Eden Health Plan State licensure; fiscal solvency.
2015 MA/PD App. 02 Sanford Heart of America Health Plan Adequacy of network.
2016 MA/PD App. 04 Boston Medical Center Health Plan Denial of service area expansion on basis that Applicant lacked 14 months of performance history.
2016 MA/PD App. 05 Viventum Health Plan State licensure.
2016 MA/PD App. 06 Anthem - BCBSA of California Adequacy of network; application process.
2016 MA/PD App. 03 United Health Group, Inc. UHC of California Adequacy of network; application process.
2017_MAPD_App_03 Bright Health Company of New York, Inc. Lack of Appropriate State Licensure.
2017_MAPD_App_04 Universal Care, Inc. Failure to Provide State Approval for d/b/a.
2017_MAPD_App_09 Health Advantage Florida, Inc. Lack of Appropriate State License.
2017_MAPD_App_10 Blue Cross and Blue Shield of Michigan Failure to meet health services management and delivery application requirement.
2018 MAPD App. 01 Golden Cross Health Plan Corp. Jurisdiction/Nullification
2018 MAPD App. 02 Longevity Health Plan of New Jersey Insurance Company, Inc. Application - Legal Entity
2018 MAPD App. 03 and 05 Bright Health Insurance Company of New York, Inc. State Licensure
2018 MAPD App. 04 Legacy Health Plan, Inc. State Licensure
2018 MAPD App. 06 HealthSpring Life and Health Insurance Company Two Year Contracting Prohibition - Non-Renewal
2018 MAPD App. 08, 09 and 10 Constellation Health, LLC State Licensure
2018 MAPD App. 11, 12, 13 and 14 Anthem, Inc. Past Performance