81 FR 65651 - Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2017

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

Federal Register Volume 81, Issue 185 (September 23, 2016)

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, 2017. The calendar year 2017 AIC threshold amounts are $160 for ALJ hearings and $1,560 for judicial review.

[Federal Register Volume 81, Number 185 (Friday, September 23, 2016)]
[Notices]
[Pages 65651-65653]
From the Federal Register Online  [www.thefederalregister.org]
[FR Doc No: 2016-23002]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4179-N]


Medicare Program; Medicare Appeals; Adjustment to the Amount in 
Controversy Threshold Amounts for Calendar Year 2017

AGENCY: Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION: Notice.

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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, 2017. 
The calendar year 2017 AIC threshold amounts are $160 for ALJ hearings 
and $1,560 for judicial review.

DATES: Effective Date: This notice is effective on January 1, 2017.

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,

[[Page 65652]]

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)).

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 2017

    The AIC threshold amount for ALJ hearing requests will rise to $160 
and the AIC threshold amount for judicial review will rise to $1,560 
for CY 2017. These amounts are based on the 56.110 percent increase in 
the medical care component of the CPI, which was at 297.600 in July 
2003 and rose to 464.582 in July 2016. The AIC threshold amount for ALJ 
hearing requests changes to $156.11 based on the 56.110 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 2017 AIC threshold amount for ALJ hearings is 
$160.00. The AIC threshold amount for judicial review changes to 
$1561.10 based on the 56.110 percent increase over the initial 
threshold amount of $1,000. This amount was rounded to the nearest 
multiple of $10, resulting in the CY 2017 AIC threshold amount of 
$1,560.00 for judicial review.

C. Summary Table of Adjustments in the AIC Threshold Amounts

    In the following table we list the CYs 2013 through 2017 threshold 
amounts.

[[Page 65653]]



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                                      CY 2013         CY 2014         CY 2015         CY 2016         CY 2017
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ALJ Hearing.....................            $140            $140            $150            $150            $160
Judicial Review.................           1,400           1,430           1,460           1,500           1,560
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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 7, 2016.
Andrew M. Slavitt,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. 2016-23002 Filed 9-22-16; 8:45 am]
 BILLING CODE 4120-01-P