[Federal Register Volume 73, Number 188 (Friday, September 26, 2008)]
[Notices]
[Pages 55847-55848]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: E8-22589]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4136-N]
Medicare Program; Medicare Appeals; Adjustment to the Amount in
Controversy Threshold Amounts for Calendar Year 2009
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, 2009.
The 2009 AIC threshold amounts are $120 for ALJ hearings and $1,220 for
judicial review.
DATES: Effective Date: This notice is effective on January 1, 2009.
FOR FURTHER INFORMATION CONTACT: Liz Hosna, (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 AIC
threshold amounts for ALJ hearing requests and judicial review at $100
and $1000, 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 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 Part 405,
Subpart I, at Sec. 405.1006(b). 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 requirement 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 (Medicare Advantage) Appeals
Section 940(b)(2) of the MMA applies the AIC adjustment requirement
to Part C (MA) appeals by amending section 1852(g)(5) of the Act. The
implementing regulations for Medicare Part C appeals are found at 42
CFR Part 422, Subpart M. Specifically, Sec. 422.600 and Sec. 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, 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 that any party, including the MA organization, may request
judicial review if the amount in controversy 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) 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 Part 422, Subpart M, and as discussed above, 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 above, 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 Part
423, Subpart M. The regulations impart at Sec. 423.562(c) 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.
423.610 and Sec. 423.630 of the Part D appeals rules discuss the AIC
threshold amounts for ALJ hearings and judicial review. Section
423.610(a)
[[Page 55848]]
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. Section 423.630(a) allows a Part D enrollee to request
judicial review of an ALJ's decision if the AIC meets the threshold
amount established annually by the Secretary.
II. 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 of 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 the July of the preceding year involved and rounded to
the nearest multiple of $10.
B. Calendar Year 2009
The AIC threshold amount for ALJ hearing requests will be $120 and
the AIC threshold amount for judicial review will be $1,220 for the
2009 calendar year. These new amounts are based on the 22.3 percent
increase in the medical care component of the CPI from July of 2003 to
July of 2008. The CPI level was at 297.6 in July of 2003 and rose to
363.96 in July of 2008. This change accounted for the 22.3 percent
increase. The AIC threshold amount for ALJ hearing requests changes to
$122.30 based on the 22.3 percent increase. In accordance with section
940 of the MMA, this amount is rounded to the nearest multiple of $10.
Therefore, the 2009 AIC threshold amount for ALJ hearings is $120. The
AIC threshold amount for judicial review changes to $1,223.00 based on
the 22.3 percent increase. This amount was rounded to the nearest
multiple of $10, resulting in a 2009 AIC threshold amount of $1,220.
C. Summary Table of Adjustments in the AIC Threshold Amounts
In Table 1 below, we list the Calendar Year 2005 through 2009
threshold amounts.
Table 1--Amount-in-Controversy Threshold Amounts
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CY 2005 CY 2006 CY 2007 CY 2008 CY 2009
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ALJ Hearing..................... $100 $110 $110 $120 $120
Judicial Review................. 1050 1090 1130 1180 1,220
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Key: CY = Calendar Year.
III. Collection of Information Requirements (If Applicable)
This document does not impose information collection and
recordkeeping requirements. Consequently, it need not be reviewed by
the Office of Management and Budget under the authority of the
Paperwork Reduction Act of 1995 (44 U.S.C. 35).
(Catalog of Federal Domestic Assistance Program No. 93.778, Medical
Assistance Program; No. 93.773 Medicare--Hospital Insurance Program;
and No. 93.774, Medicare--Supplementary Medical Insurance Program)
Dated: September 12, 2008.
Kerry Weems,
Acting Administrator, Centers for Medicare & Medicaid Services.
[FR Doc. E8-22589 Filed 9-25-08; 8:45 am]
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