80_FR_58013 80 FR 57827 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2016

80 FR 57827 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2016

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services

Federal Register Volume 80, Issue 186 (September 25, 2015)

Page Range57827-57828
FR Document2015-24359

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, 2016. The calendar year 2016 AIC threshold amounts are $150 for ALJ hearings and $1,500 for judicial review.

Federal Register, Volume 80 Issue 186 (Friday, September 25, 2015) 
[Federal Register Volume 80, Number 186 (Friday, September 25, 2015)]
[Notices]
[Pages 57827-57828]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2015-24359]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4178-N]


Medicare Program; Medicare Appeals; Adjustment to the Amount in 
Controversy Threshold Amounts for Calendar Year 2016

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, 2016. 
The calendar year 2016 AIC threshold amounts are $150 for ALJ hearings 
and $1,500 for judicial review.

DATES: Effective Date: This notice is effective on January 1, 2016.

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) hearing requests 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. The AIC threshold amounts are to be adjusted, as of January 
2005, 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.

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 the Department 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)).

[[Page 57828]]

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, Sec. Sec.  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. The Medicare 
Part C appeals rules also apply to health care prepayment plan appeals.

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. The regulations at Sec.  423.562(c) prescribe that, 
unless the Part D appeals rules provide otherwise, the Part C appeals 
rules (including the annually adjusted AIC threshold amount) apply to 
Part D appeals to the extent they are appropriate. More specifically, 
Sec. Sec.  423.1970 and 423.1976 of the Part D appeals rules discuss 
the AIC threshold amounts for ALJ hearings and judicial review. Section 
423.1970(a) grants a Part D enrollee, who is dissatisfied with the 
independent review entity (IRE) reconsideration determination, a right 
to an ALJ hearing if the amount remaining in controversy after the IRE 
reconsideration meets the threshold amount established annually by the 
Secretary. Sections 423.1976(a) and (b) allow a Part D enrollee to 
request judicial review of an ALJ or Medicare Appeals Council (MAC) 
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 2016

    The AIC threshold amount for ALJ hearing requests will remain at 
$150 and the AIC threshold amount for judicial review will rise to 
$1,500 for CY 2016. These amounts are based on the 50.125 percent 
increase in the medical care component of the CPI, which was at 297.600 
in July 2003 and rose to 446.773 in July 2015. The AIC threshold amount 
for ALJ hearing requests changes to $150.125 based on the 50.125 
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 2016 AIC threshold amount for ALJ hearings is 
$150.00. The AIC threshold amount for judicial review changes to 
$1,501.25 based on the 50.125 percent increase over the initial 
threshold amount of $1,000. This amount was rounded to the nearest 
multiple of $10, resulting in the CY 2016 AIC threshold amount of 
$1,500.00 for judicial review.

C. Summary Table of Adjustments in the AIC Threshold Amounts

    In the following table we list the CYs 2012 through 2016 threshold 
amounts.

----------------------------------------------------------------------------------------------------------------
                                     CY 2012 $       CY 2013 $       CY 2014 $       CY 2015 $       CY 2016 $
----------------------------------------------------------------------------------------------------------------
ALJ Hearing.....................             130             140             140             150             150
Judicial Review.................           1,350           1,400           1,430           1,460           1,500
----------------------------------------------------------------------------------------------------------------

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 10, 2015.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2015-24359 Filed 9-24-15; 8:45 am]
 BILLING CODE 4120-01-P

Federal Register / Vol. 80, No. 186 / Friday, September 25, 2015 / Notices 57827 Quality Reporting System (PQRS) and Clinical studies in this National FOR FURTHER INFORMATION CONTACT:Liz the Electronic Prescribing Incentive Coverage Determination (NCD) must Hosna (Katherine.Hosna@cms.hhs.gov), (eRx) Program Data Assessment, adhere to the designated timeframe and (410) 786–4993. Accuracy and Improper Payments meet standards establish by CMS in the SUPPLEMENTARY INFORMATION: Identification Support; Use: The NCD. Consistent with section 1142 of incentive and reporting programs have the Social Security Act, the Agency for I. Background data integrity issues, such as rejected Healthcare and Quality (AHRQ) Section 1869(b)(1)(E) of the Social and improper payments. This four year supports clinical research studies that Security Act (the Act), as amended by project will evaluate incentive payment CMS determines meet specifically section 521 of the Medicare, Medicaid, information for accuracy and identify identified requirements and research and SCHIP Benefits Improvement and improper payments, with the goal of questions. Protection Act of 2000 (BIPA), recovering these payments. To qualify for payment, providers established the amount in controversy Additionally, based on the project’s must prescribe beta amyloid PET for (AIC) threshold amounts for results, recommendations will be made beneficiaries with a set of clinical Administrative Law Judge (ALJ) hearing so that we can avoid future data criteria specific to each cancer. Data requests and judicial review at $100 and integrity issues. elements will be transmitted to CMS for $1,000, respectively, for Medicare Part Data submission, processing, and evaluation of the short and long-term A and Part B appeals. Section 940 of the reporting will be analyzed for potential benefits of beta amyloid PET to Medicare Prescription Drug, errors, inconsistencies, and gaps that are beneficiaries and for use in future Improvement, and Modernization Act of related to data handling, program clinical decision making. Form Number: 2003 (MMA), amended section requirements, and clinical quality CMS–10583 (OMB control number: 1869(b)(1)(E) of the Act to require the measure specifications of PQRS and eRx 0938–NEW); Frequency: Annually; AIC threshold amounts for ALJ hearings program. Surveys of Group Practices, Affected Public: Private sector (Business and judicial review to be adjusted Registries, and Data Submission or other for-profit); Number of annually. The AIC threshold amounts Vendors (DSVs) will be conducted in Respondents: 300; Total Annual are to be adjusted, as of January 2005, order to evaluate the PQRS and eRx Responses: 3,700; Total Annual Hours: by the percentage increase in the Incentive Program. Follow-up 6,475. (For policy questions regarding medical care component of the interviews will occur with a small this collection contact Stuart Caplan at consumer price index (CPI) for all urban number of respondents. Form Number: 410–786–8564). consumers (U.S. city average) for July CMS–10519 (OMB control number: Dated: September 22, 2015. 2003 to July of the year preceding the 0938–1255); Frequency: Annually; William N. Parham, III, year involved and rounded to the Affected Public: Business or other for- nearest multiple of $10. Section Director, Paperwork Reduction Staff, Office profits; Number of Respondents: 115; of Strategic Operations and Regulatory 940(b)(2) of the MMA provided Total Annual Responses: 115; Total Affairs. conforming amendments to apply the Annual Hours: 201. (For policy [FR Doc. 2015–24474 Filed 9–24–15; 8:45 am] AIC adjustment requirement to questions regarding this collection Medicare Part C/Medicare Advantage BILLING CODE 4120–01–P contact Timothy Jackson at 410–786– (MA) appeals and certain health 4006.) maintenance organization and 2. Type of Information Collection DEPARTMENT OF HEALTH AND competitive health plan appeals. Health Request: New collection (Request for a HUMAN SERVICES care prepayment plans are also subject new OMB control number); Title of to MA appeals rules, including the AIC Information Collection: Data Collection Centers for Medicare & Medicaid adjustment requirement. Section 101 of for Medicare Beneficiaries Receiving Services the MMA provides for the application of Beta Amyloid Positron Emission the AIC adjustment requirement to Tomography (PET) for Dementia and [CMS–4178–N] Medicare Part D appeals. Neurodegenerative Disease Use: In the Medicare Program; Medicare Appeals; Decision Memorandum #CAG–00431N A. Medicare Part A and Part B Appeals Adjustment to the Amount in issued on September 27, 2013, CMS The statutory formula for the annual Controversy Threshold Amounts for determined there is sufficient evidence adjustment to the AIC threshold Calendar Year 2016 that the use of beta amyloid PET is amounts for ALJ hearings and judicial promising in 2 scenarios: (1) to exclude AGENCY: Centers for Medicare & review of Medicare Part A and Part B Alzheimer’s Disease (AD) in narrowly Medicaid Services (CMS), HHS. appeals, set forth at section defined and clinically difficult ACTION: Notice. 1869(b)(1)(E) of the Act, is included in differential diagnoses; and (2) to enrich the applicable implementing clinical trials seeking better treatments SUMMARY: This notice announces the regulations, 42 CFR 405.1006(b) and (c). or prevention strategies for AD. CMS annual adjustment in the amount in The regulations require the Secretary of will cover one beta amyloid PET scan controversy (AIC) threshold amounts for the Department of Health and Human per patient through Coverage with Administrative Law Judge (ALJ) Services (the Secretary) to publish Evidence Development under section hearings and judicial review under the changes to the AIC threshold amounts 1862(a)(1)(E) of the Social Security Act, Medicare appeals process. The in the Federal Register in clinical studies that meet specific adjustment to the AIC threshold (§ 405.1006(b)(2)). In order to be entitled amounts will be effective for requests mstockstill on DSK4VPTVN1PROD with NOTICES criteria established by CMS. Clinical to a hearing before an ALJ, a party to a studies must be approved by CMS, for ALJ hearings and judicial review proceeding must meet the AIC involve subjects from appropriate filed on or after January 1, 2016. The requirements at § 405.1006(b). Similarly, populations, and be comparative and calendar year 2016 AIC threshold a party must meet the AIC requirements longitudinal. Radiopharmaceuticals amounts are $150 for ALJ hearings and at § 405.1006(c) at the time judicial used in the scan must be FDA approved. $1,500 for judicial review. review is requested for the court to have Approved studies must address defined DATES: Effective Date: This notice is jurisdiction over the appeal research questions established by CMS. effective on January 1, 2016. (§ 405.1136(a)). VerDate Sep<11>2014 19:58 Sep 24, 2015 Jkt 235001 PO 00000 Frm 00045 Fmt 4703 Sfmt 4703 E:\FR\FM\25SEN1.SGM 25SEN1

57828 Federal Register / Vol. 80, No. 186 / Friday, September 25, 2015 / Notices B. Medicare Part C/MA Appeals B, and C appeals also apply to Medicare threshold amounts be adjusted Section 940(b)(2) of the MMA applies Part D appeals. Section 101 of the MMA annually, beginning in January 2005, by the AIC adjustment requirement to added section 1860D–4(h)(1) of the Act the percentage increase in the medical Medicare Part C appeals by amending regarding Part D appeals. This statutory care component of the CPI for all urban section 1852(g)(5) of the Act. The provision requires a prescription drug consumers (U.S. city average) for July implementing regulations for Medicare plan sponsor to meet the requirements 2003 to July of the year preceding the Part C appeals are found at 42 CFR 422, set forth in sections 1852(g)(4) and (g)(5) year involved and rounded to the subpart M. Specifically, §§ 422.600 and of the Act, in a similar manner as MA nearest multiple of $10. 422.612 discuss the AIC threshold organizations. As noted previously, the amounts for ALJ hearings and judicial annually adjusted AIC threshold B. Calendar Year 2016 review. Section 422.600 grants any party requirement was added to section 1852(g)(5) of the Act by section The AIC threshold amount for ALJ to the reconsideration, except the MA hearing requests will remain at $150 organization, who is dissatisfied with 940(b)(2)(A) of the MMA. The implementing regulations for Medicare and the AIC threshold amount for the reconsideration determination, a judicial review will rise to $1,500 for CY right to an ALJ hearing as long as the Part D appeals can be found at 42 CFR 423, subparts M and U. The regulations 2016. These amounts are based on the amount remaining in controversy after at § 423.562(c) prescribe that, unless the 50.125 percent increase in the medical reconsideration meets the threshold requirement established annually by the Part D appeals rules provide otherwise, care component of the CPI, which was Secretary. Section 422.612 states, in the Part C appeals rules (including the at 297.600 in July 2003 and rose to annually adjusted AIC threshold 446.773 in July 2015. The AIC threshold part, that any party, including the MA amount) apply to Part D appeals to the amount for ALJ hearing requests organization, may request judicial extent they are appropriate. More changes to $150.125 based on the 50.125 review if the AIC meets the threshold specifically, §§ 423.1970 and 423.1976 percent increase over the initial requirement established annually by the of the Part D appeals rules discuss the threshold amount of $100 established in Secretary. AIC threshold amounts for ALJ hearings 2003. In accordance with section C. Health Maintenance Organizations, and judicial review. Section 423.1970(a) 1869(b)(1)(E)(iii) of the Act, the adjusted Competitive Medical Plans, and Health grants a Part D enrollee, who is threshold amounts are rounded to the Care Prepayment Plans dissatisfied with the independent nearest multiple of $10. Therefore, the Section 1876(c)(5)(B) of the Act states review entity (IRE) reconsideration CY 2016 AIC threshold amount for ALJ that the annual adjustment to the AIC determination, a right to an ALJ hearing if the amount remaining in controversy hearings is $150.00. The AIC threshold dollar amounts set forth in section amount for judicial review changes to 1869(b)(1)(E)(iii) of the Act applies to after the IRE reconsideration meets the threshold amount established annually $1,501.25 based on the 50.125 percent certain beneficiary appeals within the increase over the initial threshold context of health maintenance by the Secretary. Sections 423.1976(a) and (b) allow a Part D enrollee to amount of $1,000. This amount was organizations and competitive medical rounded to the nearest multiple of $10, plans. The applicable implementing request judicial review of an ALJ or Medicare Appeals Council (MAC) resulting in the CY 2016 AIC threshold regulations for Medicare Part C appeals decision if, in part, the AIC meets the amount of $1,500.00 for judicial review. are set forth in 42 CFR 422, subpart M and apply to these appeals. The threshold amount established annually C. Summary Table of Adjustments in Medicare Part C appeals rules also apply by the Secretary. the AIC Threshold Amounts to health care prepayment plan appeals. II. Provisions of the Notice—Annual AIC Adjustments In the following table we list the CYs D. Medicare Part D (Prescription Drug 2012 through 2016 threshold amounts. Plan) Appeals A. AIC Adjustment Formula and AIC The annually adjusted AIC threshold Adjustments amounts for ALJ hearings and judicial As previously noted, section 940 of review that apply to Medicare Parts A, the MMA requires that the AIC CY 2012 $ CY 2013 $ CY 2014 $ CY 2015 $ CY 2016 $ ALJ Hearing ......................................................................... 130 140 140 150 150 Judicial Review .................................................................... 1,350 1,400 1,430 1,460 1,500 III. Collection of Information Dated: September 10, 2015. DEPARTMENT OF HEALTH AND Requirements Andrew M. Slavitt, HUMAN SERVICES Acting Administrator, Centers for Medicare This document does not impose & Medicaid Services. Administration for Children and information collection requirements, Families [FR Doc. 2015–24359 Filed 9–24–15; 8:45 am] that is, reporting, recordkeeping or BILLING CODE 4120–01–P Proposed Information Collection third-party disclosure requirements. mstockstill on DSK4VPTVN1PROD with NOTICES Consequently, there is no need for Activity; Comment Request review by the Office of Management and Proposed Projects: Budget under the authority of the Title: Head Start Eligibility Paperwork Reduction Act of 1995 (44 Verification. U.S.C. 3501 et seq.). OMB No.: 0970–0374. Description: The Office of Head Start (OHS) within the Administration for VerDate Sep<11>2014 19:58 Sep 24, 2015 Jkt 235001 PO 00000 Frm 00046 Fmt 4703 Sfmt 4703 E:\FR\FM\25SEN1.SGM 25SEN1


Document Created: 2018-02-26 10:20:08
Document Modified: 2018-02-26 10:20:08
CategoryRegulatory Information
CollectionFederal Register
sudoc ClassAE 2.7:
GS 4.107:
AE 2.106:
PublisherOffice of the Federal Register, National Archives and Records Administration
SectionNotices
ActionNotice.
DatesEffective Date: This notice is effective on January 1, 2016.
ContactLiz Hosna ([email protected]), (410) 786-4993.
FR Citation80 FR 57827 
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