Medicare News
| For Immediate Release: | Contact: |
| Tuesday, April 29, 1997 | CMS Office of Public Affairs 202-690-6145 |
For questions about Medicare please call 1-800-MEDICARE or visit www.medicare.gov. |
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CLINTON ADMINISTRATION GUARANTEES RAPID RESPONSE TO MEDICARE BENEFICIARIES' APPEALS OF TREATMENT DENIALS
The Clinton administration is publishing final regulations guaranteeing that Medicare beneficiaries will receive a ruling within 72 hours when they appeal a denial-of-care decision by a health plan that could jeopardize life, health or ability to regain maximum function. The rule also covers termination of care, such as discharge from a skilled nursing facility.
The new rules replace the current system that allows for a ruling within 60 days of a beneficiary's appeal. The regulation will be published in tomorrow's Federal Register, and health plans participating in Medicare will have 120 days to put procedures in place for the expedited appeal process. The rules were formulated in consultation with consumer groups, health plans and others.
"Consumers should have the right to a speedy ruling in cases where time may be crucial," said HHS Secretary Donna E. Shalala. "These regulations will help assure that the rights of patients come first."
Secretary Shalala said the new rule "gives Medicare beneficiaries appeal rights that are among the strongest available to any managed care enrollees in the country, without putting undue burden on health care plans."
Shalala also noted the rule builds on a series of actions taken by the administration in recent months to protect and improve the rights of Medicare beneficiaries, including limits on financial incentives for physicians and a prohibition on the use of "gag rules" that limit what physicians can tell their patients about treatment options.
The rule requires health plans to notify all Medicare enrollees of their new expedited appeal rights, to use denial notice forms that describe the expedited appeal right, to accept oral requests for appeals, to follow up verbal notifications in writing within two working days, and to maintain logs and periodically report on requests for expedited appeals.
"Our beneficiaries must be assured that incentives to reduce unnecessary care will not be allowed to limit necessary care. And they must know that they have a prompt recourse if they feel that they are denied needed care," said Bruce C. Vladeck, administrator of HHS' Health Care Financing Administration, the Medicare and Medicaid agency. Vladeck added that "since the federal government is the largest purchaser of managed care, this regulation will help set a new, higher standard for the entire managed care industry."
Additional improvements to the regulations are also being developed pertaining to continuation of care during the appeal process, appeal rights when services are reduced, and tighter standards for appeals involving situations that are not urgent. Beneficiary advocates, provider groups and the managed care industry will be consulted in the development of these proposals.
