Medicare Appeals: Beneficiary Information About
Medicare Advantage

Members of Medicare Advantage Organizations (MAs) have the right to an expedited review when they disagree with their MA's decision to terminate Medicare coverage of services from a comprehensive outpatient rehabilitation facility (CORF), home health agency (HHA), or skilled nursing facility (SNF).

This appeal right (effective January 1, 2004) stems from the Grijalva lawsuit, and was established in regulations in a final rule published on April 4, 2003 (68 FR 16652). It is similar to the existing right of a Medicare beneficiary to request a review of a discharge from an inpatient hospital.

"Grijalva" refers to Grijalva v. Shalala, a class action lawsuit that challenged the adequacy of the Medicare managed care appeals process. The plaintiffs claimed that beneficiaries in Medicare managed care plans were not given adequate notice and appeal rights when coverage of their health care services was denied or terminated.

Based on the provisions of the April 2003 final rule, CORFs, HHAs, and SNFs must provide an advance notice of Medicare coverage termination to MA beneficiaries no later than two days or two visits before coverage of services will end. If the beneficiary does not agree that covered services should end, the beneficiary or his/her authorized representative may request an expedited review of the case by the Colorado Foundation for Medical Care. The beneficiary's MA must furnish a detailed notice explaining why services are no longer necessary or covered. The review process generally is completed within two days of the beneficiary's request for an appeal.

The links below open new windows:

• Beneficiary Notices Initiative (BNI)
• Presentation
• Managed Care Appeals and Grievances (Forms, Q&As, etc.)
• Comprehensive Outpatient Rehabilitation Facilities (CORFs)
• Home Health
• Skilled Nursing Facility