OM AdQIC Eligibility Contractor Activities - Statement of Work

Appendix D- Eligibility Activities

Optional Appendix D:
Scope of Work for Eligibility Contractor Activities

A. Background and Overview:

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule titled Medicare Program: Appeal Rights for Certain Changes in Patient Status-CMS-4204-P on December 27, 2023[1]. This regulation sets forth new appeals procedures to implement the court order in Alexander v. Azar, 613 F. Supp. 3d 559 (D. Conn. 2020)), aff’d sub nom., Barrows v. Becerra, 24 F.4th 116 (2d Cir. 2022). Note: CMS is currently working towards issuing the final rule. To the extent there are revisions in the final rule that have a material impact on this scope of work, CMS shall work to formally amend and revise this scope of work and any applicable requirements.
In the court order, the Department of Health and Human Services (HHS) was directed to, “. . . permit all members of the modified class to appeal the denial of Part A coverage” and to establish appeal procedures for certain beneficiaries in Original Medicare who are initially admitted to a hospital as an inpatient by a physician but whose status during their stay is changed to outpatient receiving observation services 2 by the hospital, thereby effectively denying Part A coverage for their hospital stay. In some cases, the denial of Part A coverage of the hospital stay also affects coverage of a beneficiary’s post-hospital extended care services furnished in a skilled nursing facility (SNF). The court order requires HHS to establish new retrospective appeal procedures that will enable eligible beneficiaries to appeal the denial of Part A coverage for hospital stays on or after January 1, 2009. Eligible parties will have 365 calendar days3 from the implementation date specified in the final regulation CMS-4204-F, to submit a request for retrospective appeal to the eligibility contractor.

B. Purpose

The purpose of Appendix F and the related activities as defined below is to support HHS, and more specifically, the CMS in making eligibility determinations for retrospective appeals under this new appeals process. The contractor for this effort shall be known as the “Eligibility Contractor (EC).” The EC shall serve as a single point of contact for incoming retrospective appeal requests submitted by beneficiaries (or their appointed or authorized representatives), or, as applicable, the successors filing on behalf of a deceased beneficiary, under proposed 42 Code of Federal Regulations (CFR) 405.932.