CMS’s Proposed Rule Clarifies Enrollees’ Medicare Advantage Appeal Rights for Inpatient Admissions and Level of Care Determinations

Lexology January 9, 2025
Hall Render Killian Heath & Lyman PC

On November 26, 2024, the Centers for Medicare & Medicaid Services (“CMS”) released a proposed rule that revises the Medicare Advantage (“MA”) Program, Medicare Prescription Drug Benefit Program (“Part D”), Medicare Cost Plan Program and Programs of All-Inclusive Care for the Elderly for the Contract Year 2026 (“Proposed Rule”). The Proposed Rule clarifies the definition of an organization determination that triggers enrollees’ notice and appeal rights, strengthens notice requirements and eliminates MA discretion to reopen approved authorizations.

Applicability of Appeals When “No Further Financial Liability”

A longstanding MA appeals rule states that when an enrollee receives plan-directed care from a contracted provider, the enrollee cannot be financially liable for more than the applicable cost-sharing for that service and accordingly, the...

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