Medicare Advantage & Prescription Drug Plan Appeals

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 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 Contract Determination 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
2023 H-23-00022
Sonder Health Plans, Inc.
Network Deficiency (Administrator declined review)
Longevity Health Plan of North Carolina, Inc.
Network Deficiency; Exception Request (with Administrator's Review)
Longevity Health Plan of Michigan, Inc.
Network Deficiency; Exception Request (with Administrator's Review)
2023 H-23-00017
Molina Healthcare of Nebraska, Inc.
Past Performance; Network Deficiency (Administrator declined review)
2023 H-23-00016
Molina Healthcare of Indiana, Inc.
Past Performance; Network Deficiency (Administrator declined review)
2023 H-23-00012
Zing Health, Inc.
Licensure; Past Performance; Star Ratings; Letters of Intent (Administrator declined review)
2023 H-23-00011
Lasso Healthcare Insurance Company
Past Performance; Star Ratings (Administrator declined review)
2023 H-23-00008
Provider Partners Health Plan of North Carolina
Letters of Intent (no request for Administrator review)
2023 H-23-00007
HealthSpring Life & Health Insurance
Novation; Exception Requests; Network Deficiency; Letters of Intent (no request for Administrator review)
2023 H-23-00005
VNS Choice Health Plan
Network Deficiency; Letters of Intent (no request for Administrator review)
2023 H-23-00004
Chinese Community Health Plan
Network Deficiency (Administrator declined review)
2023 H-23-00003
Verda Health Plan of Texas, Inc.
Licensure; Network Deficiency (Administrator declined review)
2023 H-23-00002
Imperial Health Plan of California
Contract Termination; Star Ratings (Administrator declined review)
2022 H-22-00016
Vitality Health Plan of California
Past Performance
2022 H-22-00015
Reliance HMO, Inc.
Past Performance
Renal Payer Solutions, Inc.
Licensure
2021 H-21-0015
Leon Health Plans, Inc.
Contracting
eternalHealth, Inc.
Contracting (with Administrator's Review)
2021 H-21-0011
Community Insurance Company
Contracting
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
2019 MAPD App. 01
Texas Independence Health Plan, Inc.
Failure to File Timely Application
Anthem, Inc.
Past Performance
Constellation Health, LLC
State Licensure
2018 MAPD App. 06
HealthSpring Life and Health Insurance Company
Two Year Contracting Prohibition - Non-Renewal
2018 MAPD App. 04
Legacy Health Plan, Inc.
State Licensure
2018 MAPD App. 03 and 05
Bright Health Insurance Company of New York, Inc.
State Licensure
2018 MAPD App. 02
Longevity Health Plan of New Jersey Insurance Company, Inc.
Application - Legal Entity
2018 MAPD App. 01
Golden Cross Health Plan Corp.
Jurisdiction/Nullification
2017 MAPD App. 10
Blue Cross and Blue Shield of Michigan
Failure to meet health services management and delivery application requirement.
2017 MAPD App. 09
Health Advantage Florida, Inc.
Lack of Appropriate State License.
2017 MAPD App. 04
Universal Care, Inc.
Failure to Provide State Approval for d/b/a.
2017 MAPD App. 03
Bright Health Company of New York, Inc.
Lack of Appropriate State Licensure.
2016 MA/PD App. 06
Anthem - BCBSA of California
Adequacy of network; application process.
2016 MA/PD App. 05
Viventum Health Plan
State licensure.
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. 03
United Health Group, Inc. UHC of California
Adequacy of network; application process.
Eden Health Plan
State licensure; fiscal solvency.
2015 MA/PD App. 02
Sanford Heart of America Health Plan
Adequacy of network.
Provider Partners Health Plan
Adequacy of network.
2014 MA/PD Apps. 10 and 11
WellCare Health Plans of New Jersey, Inc. - Denial of Initial Application, H1587
Assessment of Negative Performance Points
Harvard Pilgrim Health Care, Inc. (HPHC)
Denial of service area expansion on basis that Applicant lacked 14 months performance history.
2014 MA/PD App. 02
Arkansas Superior Select, Inc. - Denial of Initial Application, H1587
Application Process
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.
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 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.
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. 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. 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.
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.
Senior Whole Health, LLC Denial of Service Area Expansion
Lack of appropriate state licensure
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.
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 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 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 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. 02
Citrus Health Care - Denial of Service Area Expansion Contract # H5407
Use of Star Rating System to deny applications for fiscal year 2011.
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).
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.
2008 CD App. 01
Red Medica de Puerto Rico, Inc. - Initial Application Denial, H3420
Noncompliance with the MA-PD program.
Page Last Modified:
09/10/2024 06:23 PM