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From Health Law Daily, February 27, 2015

SMART Act appeal procedures implemented

By Michelle L. Oxman, J.D., LL.M.

Regulations establishing appeal procedures for insurers that receive demands from Medicare for reimbursement as primary payers become effective April 28, 2015.The Final rule implements the requirements of the Strengthening Medicare and Repaying Taxpayers (SMART) Act (P.L. 112-242),which became law on January 10, 2013 (Final rule, 80 FR 10611, February 27, 2015.)

The SMART Act. The legislation required HHS to for publish final regulations establish an administrative appeal process for “applicable plans” as defined in Soc. Sec. Act Sec. 1862(b)(8)(F) within nine months of enactment. The paragraph defines “applicable plan” as a plan of liability insurance (including self-insurance), no-fault insurance, or workers’ compensation insurance.

Issues subject to appeal. The plan has the right to appeal only when CMS or its contractor has identified it as the primary debtor by demanding payment from the plan. CMS has the right to decide whether to pursue repayment from the beneficiary or the plan. Only the question of whether the plan is primary to Medicare may be appealed. The agency’s decision to demand payment from the plan rather than the beneficiary is not appealable, even if Medicare has paid the beneficiary directly.

Appeal procedure. The plan must notify the beneficiary of its intent to appeal. The process will be essentially the same as it is for beneficiary appeals of demands for reimbursement. The first stage will be redetermination by the Medicare contractor. The subsequent stages are reconsideration by a qualified independent contractor, a hearing before an administrative law judge, and review by the Medicare Appeals Council.

MainStory: TopStory FinalRules MSPNews CMSNews

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