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HHS/CMS | RIN: 0938-AH62 | Publication ID: Fall 1997 |
Title: Medicare Program; Establishment of an Expedited Review Process for Medicare Beneficiaries Enrolled in HMOs, CMPs, and HCPPs (OMC-25-FC) | |
Abstract: This final rule establishes a new administrative review requirement for Medicare beneficiaries enrolled in health maintenance organizations (HMOs), competitive medical plans (CMPs), and health care prepayment plans (HCPPs) and will apply to part C Medicare choice plans. This rule implements section 1876(c)(5) of the Social Security Act, which specifies the appeal and grievance rights for Medicare enrollees and HMOs and CMPs. This rule requires that an HMO, CMP, or HCPP establish and maintain, as part of the health plan's appeals procedures, an expedited process for making organization determinations and reconsider determinations when an adverse determination could seriously jeopardize the life or health of the enrollee or the enrollee's ability to regain maximum function. This rule also revises the definition of appealable determinations to clarify that it includes a decision to discontinue services. | |
Agency: Department of Health and Human Services(HHS) | Priority: Other Significant |
RIN Status: Previously published in the Unified Agenda | Agenda Stage of Rulemaking: Final Rule Stage |
Major: No | Unfunded Mandates: No |
CFR Citation: 42 CFR 417.600 42 CFR 417.604 42 CFR 417.606 42 CFR 417.608 42 CFR 417.609 42 CFR 417.614 42 CFR 417.616 42 CFR 417.617 42 CFR 417.618 42 CFR 417.620 | |
Legal Authority: 42 USC 1395mm(c)(5) |
Timetable:
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Additional Information: OMC-25-F | |
Regulatory Flexibility Analysis Required: No | Government Levels Affected: Federal |
Included in the Regulatory Plan: No | |
Agency Contact: Maureen Miller Center for Health Plans and Providers Department of Health and Human Services Centers for Medicare & Medicaid Services S3-23-07, 7500 Security Boulevard, Baltimore, MD 21244-1850 Phone:410 786-1097 Email: mmiller@hcfa.gov |