Nebraska Department of Insurance
THE NEBRASKA HEALTH INSURANCE INFORMATION, COUNSELING, AND ASSISTANCE (NICA) PROGRAM
MARCH 2004 NICA NEWS
CHANGES
New LCD Appeal Rights
Medicare Carriers and Fiscal Intermediaries make coverage decisions on what specific items or services will be covered by Medicare in their coverage area. The Centers for Medicare & Medicaid Services published a final rule on November 7, 2003, establishing a process for beneficiaries to appeal these Local Coverage Determinations (LCDs). Beneficiaries already have the right to appeal individual claims denials when they believe a covered item or service was denied improperly. This Final Rule will give them an additional avenue to challenge the underlying coverage policy. Under the Final Rule, LCDs would be reviewed initially by an administrative law judge (ALJ). All ALJ decisions on LCDs would be reviewed by the Health and Human Services Departmental Appeals Board. The Board's decision could then be appealed to federal court. Decisions in these appeals may also have implications for future Medicare coverage of the item or service for all Medicare beneficiaries, not just the individual who filed the appeal.- If the beneficiary has not received the service, the request for the review must be filed within 6 months of the date the individual needs to receive that item or service. If the beneficiary has already received the item or service, the request for review must be filed within 120 days of the date of the initial denial notice.
- Appeal requests should be sent to: LCD Coordinator; 2520 Lord Baltimore Drive, Suite L; Mail Stop LB-23-20; Baltimore, MD 21244-2670
- Appeals must include the beneficiary name, address, telephone number, and health insurance claim number if applicable. (If designating an authorized representative, must include a signed written statement from the beneficiary) Appeals must also include the title of the LCD being challenged, the specific provisions of the LCD affecting the beneficiary, and the name of the contractor that used the LCD. The request must also explain why the service is needed, why the LCD is incorrect, and why the appeal request is being made. Lastly, the request must be accompanied with a written statement from the doctor treating the person, indicating that the service is needed along with any clinical or scientific information that adds validity to the basis of why the LCD should be revised or abandoned.
Medicare Select now available in Nebraska
A Medicare Select plan is a Medicare supplement policy that requires the use of in-network hospitals to be eligible for full benefits. Standard Life & Health Insurance Company is now offering a Medicare Select plan C,D,F,G in Nebraska, available for sale to residents who reside within 40 miles of a plan-participating hospital. Currently, two hospitals are participating in Standard Life & Health's plan: Nebraska Methodist in Omaha and Garden County Health Services in Oshkosh. The company does not expect a dramatic increase in participating hospitals in the near future.A beneficiary who buys a Medicare Select Medigap policy must use the in-network hospitals or they will be required to pay the Part A deductible. The benefit of the plan is that if the beneficiary does use a network hospital, neither the beneficiary nor the Medsupp policy has to pay the Part A deductible ($876 per benefit period in 2004), because the hospitals have agreed to waive payment of the deductible. This should allow Standard & Life to offer the plan C,D,F, and G at a lower premium, however the rates they have submitted to the Department of Insurance do not show a significant savings at this point. All of the other benefits under the Medicare Select plan remain the same as with any other policy of the same letter. The only difference is the Part A deductible/participating hospital requirement.