Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2020

Citation84 FR 53444
Record Number2019-21751
Published date07 October 2019
SectionNotices
CourtCenters For Medicare & Medicaid Services
Federal Register, Volume 84 Issue 194 (Monday, October 7, 2019)
[Federal Register Volume 84, Number 194 (Monday, October 7, 2019)]
                [Notices]
                [Pages 53444-53445]
                From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
                [FR Doc No: 2019-21751]
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                DEPARTMENT OF HEALTH AND HUMAN SERVICES
                Centers for Medicare & Medicaid Services
                [CMS-4186-N]
                Medicare Program; Medicare Appeals; Adjustment to the Amount in
                Controversy Threshold Amounts for Calendar Year 2020
                AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.
                ACTION: Notice.
                -----------------------------------------------------------------------
                SUMMARY: This notice announces the annual adjustment in the amount in
                controversy (AIC) threshold amounts for Administrative Law Judge (ALJ)
                hearings and judicial review under the Medicare appeals process. The
                adjustment to the AIC threshold amounts will be effective for requests
                for ALJ hearings and judicial review filed on or after January 1, 2020.
                The calendar year 2020 AIC threshold amounts are $170 for ALJ hearings
                and $1,670 for judicial review.
                DATES: This annual adjustment takes effect on January 1, 2020.
                FOR FURTHER INFORMATION CONTACT: Liz Hosna
                ([email protected]), (410) 786-4993.
                SUPPLEMENTARY INFORMATION:
                I. Background
                 Section 1869(b)(1)(E) of the Social Security Act (the Act), as
                amended by section 521 of the Medicare, Medicaid, and SCHIP Benefits
                Improvement and Protection Act of 2000 (BIPA), established the amount
                in controversy (AIC) threshold amounts for Administrative Law Judge
                (ALJ) hearings and judicial review at $100 and $1,000, respectively,
                for Medicare Part A and Part B appeals. Section 940 of the Medicare
                Prescription Drug, Improvement, and Modernization Act of 2003 (MMA),
                amended section 1869(b)(1)(E) of the Act to require the AIC threshold
                amounts for ALJ hearings and judicial review to be adjusted annually.
                Beginning in January 2005, the AIC threshold amounts are to be adjusted
                by the percentage increase in the medical care component of the
                consumer price index (CPI) for all urban consumers (U.S. city average)
                for July 2003 to July of the year preceding the year involved and
                rounded to the nearest multiple of $10. Section 940(b)(2) of the MMA
                provided conforming amendments to apply the AIC adjustment requirement
                to Medicare Part C/Medicare Advantage (MA) appeals and certain health
                maintenance organization and competitive health plan appeals. Health
                care prepayment plans are also subject to MA appeals rules, including
                the AIC adjustment requirement. Section 101 of the MMA provides for the
                application of the AIC adjustment requirement to Medicare Part D
                appeals.
                [[Page 53445]]
                A. Medicare Part A and Part B Appeals
                 The statutory formula for the annual adjustment to the AIC
                threshold amounts for ALJ hearings and judicial review of Medicare Part
                A and Part B appeals, set forth at section 1869(b)(1)(E) of the Act, is
                included in the applicable implementing regulations, 42 CFR 405.1006(b)
                and (c). The regulations require the Secretary of Health and Human
                Services (the Secretary) to publish changes to the AIC threshold
                amounts in the Federal Register (Sec. 405.1006(b)(2)). In order to be
                entitled to a hearing before an ALJ, a party to a proceeding must meet
                the AIC requirements at Sec. 405.1006(b). Similarly, a party must meet
                the AIC requirements at Sec. 405.1006(c) at the time judicial review
                is requested for the court to have jurisdiction over the appeal (Sec.
                405.1136(a)).
                B. Medicare Part C/MA Appeals
                 Section 940(b)(2) of the MMA applies the AIC adjustment requirement
                to Medicare Part C appeals by amending section 1852(g)(5) of the Act.
                The implementing regulations for Medicare Part C appeals are found at
                42 CFR 422, subpart M. Specifically, sections 422.600 and 422.612
                discuss the AIC threshold amounts for ALJ hearings and judicial review.
                Section 422.600 grants any party to the reconsideration (except the MA
                organization) who is dissatisfied with the reconsideration
                determination a right to an ALJ hearing as long as the amount remaining
                in controversy after reconsideration meets the threshold requirement
                established annually by the Secretary. Section 422.612 states, in part,
                that any party, including the MA organization, may request judicial
                review if the AIC meets the threshold requirement established annually
                by the Secretary.
                C. Health Maintenance Organizations, Competitive Medical Plans, and
                Health Care Prepayment Plans
                 Section 1876(c)(5)(B) of the Act states that the annual adjustment
                to the AIC dollar amounts set forth in section 1869(b)(1)(E)(iii) of
                the Act applies to certain beneficiary appeals within the context of
                health maintenance organizations and competitive medical plans. The
                applicable implementing regulations for Medicare Part C appeals are set
                forth in 42 CFR 422, subpart M and apply to these appeals in accordance
                with 42 CFR 417.600(b). The Medicare Part C appeals rules also apply to
                health care prepayment plan appeals in accordance with 42 CFR 417.840.
                D. Medicare Part D (Prescription Drug Plan) Appeals
                 The annually adjusted AIC threshold amounts for ALJ hearings and
                judicial review that apply to Medicare Parts A, B, and C appeals also
                apply to Medicare Part D appeals. Section 101 of the MMA added section
                1860D-4(h)(1) of the Act regarding Part D appeals. This statutory
                provision requires a prescription drug plan sponsor to meet the
                requirements set forth in sections 1852(g)(4) and (g)(5) of the Act, in
                a similar manner as MA organizations. As noted previously, the annually
                adjusted AIC threshold requirement was added to section 1852(g)(5) of
                the Act by section 940(b)(2)(A) of the MMA. The implementing
                regulations for Medicare Part D appeals can be found at 42 CFR 423,
                subparts M and U. More specifically, Sec. 423.2006 of the Part D
                appeals rules discusses the AIC threshold amounts for ALJ hearings and
                judicial review. Sections 423.2002 and 423.2006 grant a Part D
                enrollee, who is dissatisfied with the independent review entity (IRE)
                reconsideration determination, a right to an ALJ hearing if, in part,
                the amount remaining in controversy after the IRE reconsideration meets
                the threshold amount established annually by the Secretary. Sections
                423.2006 and 423.2136 allow a Part D enrollee to request judicial
                review of an ALJ or Medicare Appeals Council decision if, in part, the
                AIC meets the threshold amount established annually by the Secretary.
                II. Provisions of the Notice--Annual AIC Adjustments
                A. AIC Adjustment Formula and AIC Adjustments
                 As previously noted, section 940 of the MMA requires that the AIC
                threshold amounts be adjusted annually, beginning in January 2005, by
                the percentage increase in the medical care component of the CPI for
                all urban consumers (U.S. city average) for July 2003 to July of the
                year preceding the year involved and rounded to the nearest multiple of
                $10.
                B. Calendar Year 2020
                 The AIC threshold amount for ALJ hearings will rise to $170 and the
                AIC threshold amount for judicial review will rise to $1,670 for CY
                2020. These amounts are based on the 67.234 percent increase in the
                medical care component of the CPI, which was at 297.600 in July 2003
                and rose to 497.687 in July 2019. The AIC threshold amount for ALJ
                hearings changes to $167.23 based on the 67.234 percent increase over
                the initial threshold amount of $100 established in 2003. In accordance
                with section 1869(b)(1)(E)(iii) of the Act, the adjusted threshold
                amounts are rounded to the nearest multiple of $10. Therefore, the CY
                2020 AIC threshold amount for ALJ hearings is $170.00. The AIC
                threshold amount for judicial review changes to $1,672.34 based on the
                67.234 percent increase over the initial threshold amount of $1,000.
                This amount was rounded to the nearest multiple of $10, resulting in
                the CY 2020 AIC threshold amount of $1,670.00 for judicial review.
                C. Summary Table of Adjustments in the AIC Threshold Amounts
                 In the following table we list the CYs 2016 through 2020 threshold
                amounts.
                ----------------------------------------------------------------------------------------------------------------
                 CY 2016 CY 2017 CY 2018 CY 2019 CY 2020
                ----------------------------------------------------------------------------------------------------------------
                ALJ Hearing..................... $150 $160 $160 $160 $170
                Judicial Review................. 1,500 1,560 1,600 1,630 1,670
                ----------------------------------------------------------------------------------------------------------------
                III. Collection of Information Requirements
                 This document does not impose information collection requirements,
                that is, reporting, recordkeeping or third-party disclosure
                requirements. Consequently, there is no need for review by the Office
                of Management and Budget under the authority of the Paperwork Reduction
                Act of 1995 (44 U.S.C. 3501 et seq.).
                 Dated: September 24, 2019.
                Seema Verma,
                Administrator, Centers for Medicare & Medicaid Services.
                [FR Doc. 2019-21751 Filed 10-4-19; 8:45 am]
                BILLING CODE 4120-01-P
                

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