FROM: Theodore O. Will, Chief Executive Officer
DATE: Dec 17, 2003
SUBJECT: Information For HHAs, NFs And CORFs - "Fast Track Appeals" For Medicare+Choice Organization Enrollees
IPRO CONTACTS:
Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423
Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364
The following information is in regard to a new Medicare regulation pertaining to the rights of Medicare Plus Choice (M+CO) enrollees. The regulation, effective January 1, 2004, addresses M+C organizations' termination of service coverage. Termination of service coverage is an M+C organizational decision to discontinue coverage of services being provided to an M+CO enrollee. This information is applicable only to M+CO enrollees who are receiving home health care services, skilled nursing services in a nursing facility or comprehensive outpatient rehabilitation facilities services.
Prior to an M+C organization terminating coverage service, the HHA/NF/CORF will be required to deliver an "advance notice" to the M+C patient. The intent of an advance notice is to inform the patient of an end date for M+C coverage of the health care service being provided, allowing time for an appeal if the patient disagrees with the coverage end date. Because of the advance notice, if an appeal were unsuccessful, the most the enrollee would be financially liable for would be one (1) day of services.
Appeals will be conducted seven (7) days/week (including weekends and holidays) by IPRO, the Medicare Quality Improvement Organization (QIO), for New York. The regulation requires that a copy of the enrollee's medical record be provided to the QIO no later than close of business of the day the request for an appeal was made.
IPRO must then contact the M+CO (at the time of the appeal) in order to request medical records and any other required information. IPRO must also contact the health service Provider.
To facilitate this appeal process, IPRO is requesting contact information for your organization. Please complete the "Fax-Back Form" and return it to the attention of Lori DeRise no later than December 26, 2003.
IPRO
1979 Marcus Avenue
Lake Success, N.Y. 11042-1002
IPRO Fax # 516-326-6176
The Centers for Medicare & Medicaid Services (CMS) require that health care providers deliver the advance notice "Important Medicare Message of Non-Coverage". This is a standardized, largely generic, notice to be given to each M+C enrollee prior to the M+C organization terminating coverage of a health care service. The notice contains only two patient-specific elements-the patient's name and the date services will end. These advance notices provide standardized information on a patient's appeal rights and instructions on how to initiate an appeal, if necessary.
CMS believes that HHAs/NFs/CORFs, as providers, are in a better position than M+C organizations to carry out routine delivery of service termination notices to their patients. The HHA/NF/CORF will deliver the advance notice and, if the patient disagrees with the termination of services, the M+C organization will follow-up with a detailed notice.
The HHA's/NF's/CORF's obligation to give an advance termination notice to the patient exists even if HHA/NF/CORF or the attending physician disagrees with the M+C organization that services should terminate. The M+C organization's decision to end services is not an indication that the HHA/NF/CORF necessarily agrees services should end, but it is necessary to ensure the patient has the opportunity to appeal the M+C organization's decision.
Example: An M+C enrollee has been receiving home health or physical therapy services each Monday and Thursday. The M+C organization notifies the HHA/CORF that coverage will be terminated, with a Friday effective date. The HHA/CORF must issue a notice no later than Monday (the next to last time the service is to be furnished).
Example: A physician writes an order stating a nursing facility patient may be discharged on a Tuesday; however, the advance notice had been issued listing a termination date of Thursday. If the patient agrees with the doctor's order, he or she may be discharged on Tuesday. The notice simply informed the patient that M+C coverage would end Thursday.
Example 1: A physician writes an order stating a patient no longer requires home health care services on a Tuesday; however, the advance notice had been issued listing a termination date of Thursday. If the patient agrees with the doctor's order, he or she may decline services beginning Tuesday. The advance notice simply informed the patient that M+C coverage would end Thursday.
Example 2: A physician writes an order stating a patient in the nursing facility may be discharged on a Tuesday; however, the advance notice had been issued listing a termination date of Thursday. If the patient agrees with the doctor's order, he or she may be discharged on Tuesday. The notice simply informed the patient that M+C coverage would end Thursday.
In addition, the patient must be competent to sign the notice. An incapacitated patient is not able to comprehend his or her rights and, therefore, could not validly "receive" the notice. This situation could be remedied through the use of an authorized representative under Federal or State law.
Example: If a patient with a diagnosis of senile dementia signed, the advance notice would not be considered valid. The HHA/NF/CORF should have been aware of the patient's inability to accept delivery of the notice based on typical activities that take place during a course of treatment.
Should you have any questions or require additional information, please do not hesitate to contact Alice Vallar, Senior Director, Medicare/Federal Health Care Assessment, extension 423 or Andrea Goldstein, Vice President, Medicare/Federal Health Care Assessment, extension 364.