80 FR 73782 - Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-July Through September 2015
DEPARTMENT OF HEALTH AND HUMAN SERVICES Federal Register Volume 80, Issue 227 (November 25, 2015)
Federal Register Volume 80, Issue 227 (November 25, 2015)
| Page Range | 73782-73783 | |
| FR Document | 2015-30044 |
[Federal Register Volume 80, Number 227 (Wednesday, November 25, 2015)] [Notices] [Pages 73782-73783] From the Federal Register Online [www.thefederalregister.org] [FR Doc No: 2015-30044] ----------------------------------------------------------------------- DEPARTMENT OF HEALTH AND HUMAN SERVICES [OMHA-1502-N] Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances--July Through September 2015 AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS. ACTION: Notice. ----------------------------------------------------------------------- SUMMARY: This quarterly notice lists the OMHA Case Processing Manual (OCPM) manual instructions that were published from July through September 2015. This manual standardizes the day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations and OMHA directives, and gives OMHA staff direction for processing appeals at the OMHA level of adjudication. FOR FURTHER INFORMATION CONTACT: Amanda Axeen, by telephone at (571) 777-2705, or by email at [email protected]. SUPPLEMENTARY INFORMATION: I. Background The Office of Medicare Hearings and Appeals (OMHA), a staff division within the Office of the Secretary of the U.S. Department of Health and Human Services (HHS), administers the nationwide Administrative Law Judge (ALJ) hearing program for Medicare claim, organization and coverage determination, and entitlement appeals under sections 1869, 1155, 1876(c)(5)(B), 1852(g)(5), and 1860D-4(h) of the Social Security Act (the Act). OMHA ensures that Medicare beneficiaries and the providers and suppliers that furnish items or services to Medicare beneficiaries, as well as Medicare Advantage Organizations (MAOs) and Medicaid State Agencies, have a fair and impartial forum to address disagreements with Medicare coverage and payment determinations made by Medicare contractors, MAOs, or Part D Plan Sponsors (PDPSs), and determinations related to Medicare eligibility and entitlement, Part B late enrollment penalties, and income-related monthly adjustment amounts (IRMAA) made by the Social Security Administration (SSA). The Medicare claim, organization and coverage determination appeals processes consist of four levels of administrative review, and a fifth level of review with the Federal district courts after administrative remedies under HHS regulations have been exhausted. The first two levels of review are administered by the Centers for Medicare & Medicaid Services (CMS) and conducted by Medicare contractors for claim appeals, by MAOs and an independent review entity for Part C organization determination appeals, or by PDPSs and an independent review entity for Part D coverage determination appeals. The third level of review is administered by OMHA and conducted by Administrative Law Judges. The fourth level of review is administered by the HHS Departmental Appeals Board (DAB) and conducted by the Medicare Appeals Council. In addition, OMHA and the DAB administer the second and third levels of appeal, respectively, for Medicare eligibility, entitlement, Part B late enrollment penalty, and IRMAA reconsiderations made by SSA; a fourth level of review with the Federal district courts is available after administrative remedies within SSA and HHS have been exhausted. Sections 1869, 1155, 1876(c)(5)(B), 1852(g)(5), and 1860D-4(h) of the Act are implemented through the regulations at 42 CFR part 405, subparts I and J; part 417, subpart Q; part 422, subpart M; part 423, subparts M and U; and part 478, subpart B. As noted above, OMHA administers the nationwide Administrative Law Judge hearing program in accordance with these statutes and applicable regulations. As part of that effort, OMHA has established the OMHA Case Processing Manual (OCPM). Through the OCPM, the OMHA Chief Administrative Law Judge establishes the day-to-day procedures for carrying out adjudicative functions, in accordance with applicable statutes, regulations and OMHA directives. The OCPM provides direction for processing appeals at the OMHA level of adjudication for Medicare Part A and B claims; Part C organization determinations; Part D coverage determinations; and SSA eligibility and entitlement, Part B late [[Page 73783]] enrollment penalty, and IRMAA determinations. Section 1871(c) of the Act requires that we publish a list of all Medicare manual instructions, interpretive rules, statements of policy, and guidelines of general applicability not issued as regulations at least every 3 months in the Federal Register. II. Format for the Quarterly Issuance Notices This quarterly notice provides the specific updates to the OCPM that have occurred in the 3-month period. A hyperlink to the available chapters on the OMHA Web site is provided below. The OMHA Web site contains the most current, up-to-date chapters and revisions to chapters, and will be available earlier than we publish our quarterly notice. We believe the OMHA Web site list provides more timely access to the current OCPM chapters for those involved in the Medicare claim, organization and coverage determination and entitlement appeals processes. We also believe the Web site offers the public a more convenient tool for real time access to current OCPM provisions. In addition, OMHA has a listserv to which the public can subscribe to receive immediate notification of any updates to the OMHA Web site. This listserv avoids the need to check the OMHA Web site, as update notifications are sent to subscribers as they occur. If accessing the OMHA Web site proves to be difficult, the contact person listed above can provide the information. III. How To Use the Notice This notice lists the OCPM chapters and subjects published during the quarter covered by the notice so the reader may determine whether any are of particular interest. We expect this notice to be used in concert with the previously published notice. The OCPM can be accessed at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html. IV. OCPM Releases for July Through September 2015 The OCPM is used by OMHA adjudicators and staff to administer the OMHA program. It offers day-to-day operating instructions, policies, and procedures based on statutes and regulations, and OMHA directives. The following is a list and description of new and revised OCPM provisions, and the subject matter, that have been released in the covered 3-month period. The full text of current OCPM provisions is available on our Web site at http://www.hhs.gov/omha/OMHA_Case_Processing_Manual/index.html. OCPM Division I: General Matters Chapter 4, Parties. This new chapter describes who qualify as parties to the ALJ hearing and review process under the applicable authorities to guide OMHA ALJs and support staff in ensuring those filing requests for hearing and requests for review with OMHA have standing to pursue appeals, and notices and other correspondence are sent to the appropriate individuals and entities in accordance with the authorities. Chapter 5, Representatives. This new chapter describes the roles and responsibilities of party representatives in the ALJ hearing and review process, as well as the requirements to substantiate that an individual is authorized or appointed to act as a party representative under the applicable authorities. Chapter 6, CMS and CMS Contractor Roles. This new chapter describes the roles and responsibilities of CMS and its contractors in the ALJ hearing and review process, including under what conditions and how CMS or a contractor may participate in the process, including at oral hearings before OMHA ALJs, in accordance with the applicable authorities. OCPM Division II: Part A/B Claim Determinations Chapter 3, Procedural Screening. This chapter has been updated to correct a typographical error. No substantive changes were made to the chapter. Dated: _November 17, 2015. Nancy J. Griswold, Chief Administrative Law Judge, Office of Medicare Hearings and Appeals. [FR Doc. 2015-30044 Filed 11-24-15; 8:45 am] BILLING CODE 4152-01-P
![73782 Federal Register / Vol. 80, No. 227 / Wednesday, November 25, 2015 / Notices
TABLE 1—FEDERAL MEDICAL ASSISTANCE PERCENTAGES AND ENHANCED FEDERAL MEDICAL ASSISTANCE PERCENTAGES,
EFFECTIVE OCTOBER 1, 2016–SEPTEMBER 30, 2017 (FISCAL YEAR 2017)—Continued
Enhanced
Enhanced Federal Med-
Federal Med- Federal Med- ical Assistance
State ical Assistance ical Assistance percentages
percentages percentages with ACA 23
PT increase ***
South Carolina ............................................................................................................................. 71.30 79.91 100.00
South Dakota ............................................................................................................................... 54.94 68.46 91.46
Tennessee ................................................................................................................................... 64.96 75.47 98.47
Texas ........................................................................................................................................... 56.18 69.33 92.33
Utah ............................................................................................................................................. 69.90 78.93 100.00
Vermont ....................................................................................................................................... 54.46 68.12 91.12
Virgin Islands * ............................................................................................................................. 55.00 68.50 91.50
Virginia ......................................................................................................................................... 50.00 65.00 88.00
Washington .................................................................................................................................. 50.00 65.00 88.00
West Virginia ................................................................................................................................ 71.80 80.26 100.00
Wisconsin ..................................................................................................................................... 58.51 70.96 93.96
Wyoming ...................................................................................................................................... 50.00 65.00 88.00
* For purposes of section 1118 of the Social Security Act, the percentage used under titles I, X, XIV, and XVI will be 75 per centum.
** The values for the District of Columbia in the table were set for the state plan under titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, the percentage for DC is 50.00, unless otherwise specified by law.
*** Section 2101(a) of the Affordable Care Act amended Section 2105(b) of the Social Security Act to increase the enhanced FMAP for states
by 23 percentage points, but not to exceed 100 percent, for the period that begins on October 1, 2015 and ends on September 30, 2019 (fiscal
years 2016 through 2019).
[FR Doc. 2015–30050 Filed 11–24–15; 8:45 am] nationwide Administrative Law Judge administered by OMHA and conducted
BILLING CODE 4150–05–P (ALJ) hearing program for Medicare by Administrative Law Judges. The
claim, organization and coverage fourth level of review is administered by
determination, and entitlement appeals the HHS Departmental Appeals Board
DEPARTMENT OF HEALTH AND under sections 1869, 1155, (DAB) and conducted by the Medicare
HUMAN SERVICES 1876(c)(5)(B), 1852(g)(5), and 1860D– Appeals Council. In addition, OMHA
[OMHA–1502–N] 4(h) of the Social Security Act (the Act). and the DAB administer the second and
OMHA ensures that Medicare third levels of appeal, respectively, for
Medicare Program; Administrative Law beneficiaries and the providers and Medicare eligibility, entitlement, Part B
Judge Hearing Program for Medicare suppliers that furnish items or services late enrollment penalty, and IRMAA
Claim and Entitlement Appeals; to Medicare beneficiaries, as well as reconsiderations made by SSA; a fourth
Quarterly Listing of Program Medicare Advantage Organizations level of review with the Federal district
Issuances—July Through September (MAOs) and Medicaid State Agencies, courts is available after administrative
2015 have a fair and impartial forum to remedies within SSA and HHS have
address disagreements with Medicare been exhausted.
AGENCY: Office of Medicare Hearings coverage and payment determinations
and Appeals (OMHA), HHS. Sections 1869, 1155, 1876(c)(5)(B),
made by Medicare contractors, MAOs, 1852(g)(5), and 1860D–4(h) of the Act
ACTION: Notice. or Part D Plan Sponsors (PDPSs), and are implemented through the
SUMMARY: This quarterly notice lists the determinations related to Medicare regulations at 42 CFR part 405, subparts
OMHA Case Processing Manual (OCPM) eligibility and entitlement, Part B late I and J; part 417, subpart Q; part 422,
manual instructions that were published enrollment penalties, and income- subpart M; part 423, subparts M and U;
from July through September 2015. This related monthly adjustment amounts and part 478, subpart B. As noted above,
manual standardizes the day-to-day (IRMAA) made by the Social Security OMHA administers the nationwide
procedures for carrying out adjudicative Administration (SSA). Administrative Law Judge hearing
functions, in accordance with The Medicare claim, organization and program in accordance with these
applicable statutes, regulations and coverage determination appeals statutes and applicable regulations. As
OMHA directives, and gives OMHA processes consist of four levels of part of that effort, OMHA has
staff direction for processing appeals at administrative review, and a fifth level established the OMHA Case Processing
the OMHA level of adjudication. of review with the Federal district Manual (OCPM). Through the OCPM,
FOR FURTHER INFORMATION CONTACT: courts after administrative remedies the OMHA Chief Administrative Law
Amanda Axeen, by telephone at (571) under HHS regulations have been Judge establishes the day-to-day
777–2705, or by email at exhausted. The first two levels of review procedures for carrying out adjudicative
amanda.axeen@hhs.gov. are administered by the Centers for functions, in accordance with
SUPPLEMENTARY INFORMATION: Medicare & Medicaid Services (CMS) applicable statutes, regulations and
tkelley on DSK3SPTVN1PROD with NOTICES
and conducted by Medicare contractors OMHA directives. The OCPM provides
I. Background for claim appeals, by MAOs and an direction for processing appeals at the
The Office of Medicare Hearings and independent review entity for Part C OMHA level of adjudication for
Appeals (OMHA), a staff division within organization determination appeals, or Medicare Part A and B claims; Part C
the Office of the Secretary of the U.S. by PDPSs and an independent review organization determinations; Part D
Department of Health and Human entity for Part D coverage determination coverage determinations; and SSA
Services (HHS), administers the appeals. The third level of review is eligibility and entitlement, Part B late
VerDate Sep<11>2014 19:15 Nov 24, 2015 Jkt 238001 PO 00000 Frm 00085 Fmt 4703 Sfmt 4703 E:\FR\FM\25NON1.SGM 25NON1](https://thefederalregister.org/doc/80_FR_74009/page/1.svg)
![Federal Register / Vol. 80, No. 227 / Wednesday, November 25, 2015 / Notices 73783
enrollment penalty, and IRMAA at http://www.hhs.gov/omha/OMHA_ property such as patentable material,
determinations. Case_Processing_Manual/index.html. and personal information concerning
Section 1871(c) of the Act requires individuals associated with the grant
OCPM Division I: General Matters
that we publish a list of all Medicare applications, the disclosure of which
manual instructions, interpretive rules, Chapter 4, Parties. This new chapter would constitute a clearly unwarranted
statements of policy, and guidelines of describes who qualify as parties to the invasion of personal privacy.
general applicability not issued as ALJ hearing and review process under Name of Committee: National Institute of
regulations at least every 3 months in the applicable authorities to guide Mental Health Special Emphasis Panel AIDS
the Federal Register. OMHA ALJs and support staff in Research Centers on Mental Health and HIV/
ensuring those filing requests for AIDS (P30).
II. Format for the Quarterly Issuance hearing and requests for review with Date: December 2, 2015.
Notices OMHA have standing to pursue appeals, Time: 12:00 p.m. to 5:00 p.m.
and notices and other correspondence Agenda: To review and evaluate grant
This quarterly notice provides the applications.
specific updates to the OCPM that have are sent to the appropriate individuals
Place: National Institutes of Health,
occurred in the 3-month period. A and entities in accordance with the Neuroscience Center, 6001 Executive
hyperlink to the available chapters on authorities. Boulevard, Rockville, MD 20852, (Telephone
the OMHA Web site is provided below. Chapter 5, Representatives. This new Conference Call).
The OMHA Web site contains the most chapter describes the roles and Contact Person: David W. Miller, Ph.D.,
current, up-to-date chapters and responsibilities of party representatives Scientific Review Officer, Division of
revisions to chapters, and will be in the ALJ hearing and review process, Extramural Activities, National Institute of
as well as the requirements to Mental Health, NIH, Neuroscience Center,
available earlier than we publish our 6001 Executive BLVD, Room 6140, MSC
quarterly notice. We believe the OMHA substantiate that an individual is
9608, Bethesda, MD 20892–9608, 301–443–
Web site list provides more timely authorized or appointed to act as a party
9734, millerda@mail.nih.gov.
access to the current OCPM chapters for representative under the applicable
This notice is being published less than 15
those involved in the Medicare claim, authorities.
days prior to the meeting due to the timing
organization and coverage Chapter 6, CMS and CMS Contractor limitations imposed by the review and
determination and entitlement appeals Roles. This new chapter describes the funding cycle.
processes. We also believe the Web site roles and responsibilities of CMS and its (Catalogue of Federal Domestic Assistance
offers the public a more convenient tool contractors in the ALJ hearing and Program No. 93.242, Mental Health Research
for real time access to current OCPM review process, including under what Grants, National Institutes of Health, HHS)
provisions. In addition, OMHA has a conditions and how CMS or a contractor Dated: November 18, 2015.
listserv to which the public can may participate in the process,
Carolyn A. Baum,
subscribe to receive immediate including at oral hearings before OMHA
ALJs, in accordance with the applicable Program Analyst, Office of Federal Advisory
notification of any updates to the Committee Policy.
OMHA Web site. This listserv avoids authorities.
[FR Doc. 2015–29942 Filed 11–24–15; 8:45 am]
the need to check the OMHA Web site, OCPM Division II: Part A/B Claim BILLING CODE 4140–01–P
as update notifications are sent to Determinations
subscribers as they occur. If accessing
Chapter 3, Procedural Screening. This
the OMHA Web site proves to be DEPARTMENT OF HEALTH AND
chapter has been updated to correct a
difficult, the contact person listed above HUMAN SERVICES
typographical error. No substantive
can provide the information.
changes were made to the chapter.
III. How To Use the Notice National Institutes of Health
Dated: _November 17, 2015.
This notice lists the OCPM chapters Nancy J. Griswold, Center for Scientific Review; Notice of
and subjects published during the Chief Administrative Law Judge, Office of Closed Meeting
quarter covered by the notice so the Medicare Hearings and Appeals.
Pursuant to section 10(d) of the
reader may determine whether any are [FR Doc. 2015–30044 Filed 11–24–15; 8:45 am] Federal Advisory Committee Act, as
of particular interest. We expect this BILLING CODE 4152–01–P amended (5 U.S.C. App.), notice is
notice to be used in concert with the hereby given of the following meeting.
previously published notice. The OCPM The meeting will be closed to the
can be accessed at http://www.hhs.gov/ DEPARTMENT OF HEALTH AND public in accordance with the
omha/OMHA_Case_Processing_ HUMAN SERVICES provisions set forth in sections
Manual/index.html. 552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
National Institutes of Health
IV. OCPM Releases for July Through as amended. The grant applications and
September 2015 National Institute of Mental Health; the discussions could disclose
Notice of Closed Meeting confidential trade secrets or commercial
The OCPM is used by OMHA property such as patentable material,
adjudicators and staff to administer the Pursuant to section 10(d) of the and personal information concerning
OMHA program. It offers day-to-day Federal Advisory Committee Act, as individuals associated with the grant
operating instructions, policies, and amended (5 U.S.C. App.), notice is applications, the disclosure of which
procedures based on statutes and hereby given of the following meeting. would constitute a clearly unwarranted
tkelley on DSK3SPTVN1PROD with NOTICES
regulations, and OMHA directives. The meeting will be closed to the invasion of personal privacy.
The following is a list and description public in accordance with the
Name of Committee: Center for Scientific
of new and revised OCPM provisions, provisions set forth in sections Review Special Emphasis Panel;
and the subject matter, that have been 552b(c)(4) and 552b(c)(6), Title 5 U.S.C., Pathogenesis of Rare Diseases.
released in the covered 3-month period. as amended. The grant applications and Date: November 20, 2015–November 20,
The full text of current OCPM the discussions could disclose 2016.
provisions is available on our Web site confidential trade secrets or commercial Time: 2:00 p.m. to 4:00 p.m.
VerDate Sep<11>2014 19:15 Nov 24, 2015 Jkt 238001 PO 00000 Frm 00086 Fmt 4703 Sfmt 4703 E:\FR\FM\25NON1.SGM 25NON1](https://thefederalregister.org/doc/80_FR_74009/page/2.svg)
Document Created: 2018-03-01 11:16:16
Document Modified: 2018-03-01 11:16:16
| Category | Regulatory Information | |
| Collection | Federal Register | |
| sudoc Class | AE 2.7: GS 4.107: AE 2.106: | |
| Publisher | Office of the Federal Register, National Archives and Records Administration | |
| Section | Notices | |
| Action | Notice. | |
| Contact | Amanda Axeen, by telephone at (571) 777-2705, or by email at [email protected] | |
| FR Citation | 80 FR 73782 |
2025 Federal Register | Disclaimer | Privacy Policy
USC | CFR | eCFR