FAQs - The Medicare Appeals Program
|Levels of the Appeals Process||
|Types of Medicare||
The Office of Medicare Hearings and Appeals (OMHA) at the U.S. Department of Health and Human Services (HHS) provides an opportunity for individuals and organizations who are dissatisfied with Medicare initial decisions about Medicare benefits or eligibility to have a hearing in front of an Administrative Law Judge. OMHA is responsible for Level 3 of the Medicare claims appeal process, and certain Medicare entitlement and Part B premium appeals.
The appeals process is described in the section titled "The Appeals Process."
One of five phases in the Medicare appeals process at which a Medicare beneficiary or appointed representative can challenge a prior decision about a Medicare benefit before proceeding to a higher level decision-maker. There are five levels in the Medicare appeals process.
At Level 1, your appeal has different names depending on the part of Medicare under which the medical services or items were provided. For more information, see the section on Level 1 Appeals.
These are the names of Level 1 appeals for each part of the Medicare program:
Parts A & B, Original Medicare:
Includes the Hospital Insurance program (Part A) and Supplementary Medical Insurance program (Part B)
|Organization determination||Part C, the Medicare Advantage program|
|Coverage determination||Part D, the Medicare Prescription Drug program|
At Level 2, your appeal has different names depending on the part of Medicare under which the medical services or items were provided. For more information, see the section on Level 2 Appeals.
Level 3 is described in the section titled Level 3: OMHA.
At Level 4 of the appeals process, a beneficiary can appeal the decision of the OMHA adjudicator to the Medicare Appeals Council of the Departmental Appeals Board within the U.S. Department of Health and Human Services.
A Board established in the Office of the Secretary of the U.S. Department of Health and Human Services (DHHS) whose members act in panels to provide impartial review of disputed decisions made by operating components of the Department or by its adjudicators. The Medicare Appeals Council is a division of the DAB.
A division within Departmental Appeals Board that reviews and can hear cases following a decision or dismissal by an OMHA adjudicator pertaining to Medicare claims and entitlement appeals. The Medicare Appeals Council has a right to refuse to hear a case.
At Level 5 of the appeals process, a beneficiary can appeal the decision of the Medicare Appeals Council to the U.S. District Court for the jurisdiction in which the beneficiary lives and obtain court review.
Prior to January 2007, the Federal Government paid approximately 75 percent of the Part B premium and the beneficiary paid the remaining 25 percent. Starting in January 2007, beneficiaries enrolled in Medicare Part B with modified adjusted gross incomes (MAGI) above a set threshold are required to pay a higher percentage of their total Part B premium costs. This is the Income-Related Monthly Adjustment Amount (IRMAA) which may also be referred to as the Medicare subsidy reduction.
This increase will be phased in from 2007 to 2009. In 2007, affected beneficiaries will pay 33 percent of the Income-Related Monthly Adjustment Amount. In 2008, affected beneficiaries will pay 67 percent and in 2009, affected beneficiaries will pay the entire Income-Related Monthly Adjustment Amount.
Part A Hospital Insurance and Part B Supplementary Medical Insurance are often called “Original Medicare.”
Under the Medicare Prescription Drug program (Part D), beneficiaries obtain help in paying for certain medications doctors prescribe for treatment. In this program, Medicare beneficiaries obtain prescription drugs through Medicare Prescription Drug Plans.
There are four distinct health insurance programs within the Medicare program and each has its own appeals process. These health insurance programs are referred to as “parts” as each program is set forth in separate “parts” of the Medicare statute. It is important that you know under what “part” of the Medicare program you received medical services or items in order to appeal a decision regarding those benefits.
Part A is Medicare’s Hospital Insurance program which helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.
Part B is Medicare’s Supplementary Medical Insurance program that helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.
Part C of the Medicare program provides all Part A and Part B services and in some cases, some additional services, through Medicare Advantage health plans.
Part D of the Medicare program helps pay for certain medications that doctors prescribe for treatment. Beneficiaries obtain prescription drugs through Medicare Prescription Drug Plans.