Medicare Program; Administrative Law Judge Hearing Program for Medicare Claim and Entitlement Appeals; Quarterly Listing of Program Issuances-July Through September 2015, 73782-73783 [2015-30044]
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73782
Federal Register / Vol. 80, No. 227 / Wednesday, November 25, 2015 / Notices
TABLE 1—FEDERAL MEDICAL ASSISTANCE PERCENTAGES AND ENHANCED FEDERAL MEDICAL ASSISTANCE PERCENTAGES,
EFFECTIVE OCTOBER 1, 2016–SEPTEMBER 30, 2017 (FISCAL YEAR 2017)—Continued
Federal Medical Assistance
percentages
State
Enhanced
Federal Medical Assistance
percentages
Enhanced
Federal Medical Assistance
percentages
with ACA 23
PT increase ***
71.30
54.94
64.96
56.18
69.90
54.46
55.00
50.00
50.00
71.80
58.51
50.00
79.91
68.46
75.47
69.33
78.93
68.12
68.50
65.00
65.00
80.26
70.96
65.00
100.00
91.46
98.47
92.33
100.00
91.12
91.50
88.00
88.00
100.00
93.96
88.00
South Carolina .............................................................................................................................
South Dakota ...............................................................................................................................
Tennessee ...................................................................................................................................
Texas ...........................................................................................................................................
Utah .............................................................................................................................................
Vermont .......................................................................................................................................
Virgin Islands * .............................................................................................................................
Virginia .........................................................................................................................................
Washington ..................................................................................................................................
West Virginia ................................................................................................................................
Wisconsin .....................................................................................................................................
Wyoming ......................................................................................................................................
* For purposes of section 1118 of the Social Security Act, the percentage used under titles I, X, XIV, and XVI will be 75 per centum.
** The values for the District of Columbia in the table were set for the state plan under titles XIX and XXI and for capitation payments and DSH
allotments under those titles. For other purposes, the percentage for DC is 50.00, unless otherwise specified by law.
*** Section 2101(a) of the Affordable Care Act amended Section 2105(b) of the Social Security Act to increase the enhanced FMAP for states
by 23 percentage points, but not to exceed 100 percent, for the period that begins on October 1, 2015 and ends on September 30, 2019 (fiscal
years 2016 through 2019).
[FR Doc. 2015–30050 Filed 11–24–15; 8:45 am]
BILLING CODE 4150–05–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
[OMHA–1502–N]
Medicare Program; Administrative Law
Judge Hearing Program for Medicare
Claim and Entitlement Appeals;
Quarterly Listing of Program
Issuances—July Through September
2015
Office of Medicare Hearings
and Appeals (OMHA), HHS.
ACTION: Notice.
AGENCY:
This quarterly notice lists the
OMHA Case Processing Manual (OCPM)
manual instructions that were published
from July through September 2015. This
manual standardizes the day-to-day
procedures for carrying out adjudicative
functions, in accordance with
applicable statutes, regulations and
OMHA directives, and gives OMHA
staff direction for processing appeals at
the OMHA level of adjudication.
FOR FURTHER INFORMATION CONTACT:
Amanda Axeen, by telephone at (571)
777–2705, or by email at
amanda.axeen@hhs.gov.
SUPPLEMENTARY INFORMATION:
tkelley on DSK3SPTVN1PROD with NOTICES
SUMMARY:
I. Background
The Office of Medicare Hearings and
Appeals (OMHA), a staff division within
the Office of the Secretary of the U.S.
Department of Health and Human
Services (HHS), administers the
VerDate Sep<11>2014
19:15 Nov 24, 2015
Jkt 238001
nationwide Administrative Law Judge
(ALJ) hearing program for Medicare
claim, organization and coverage
determination, and entitlement appeals
under sections 1869, 1155,
1876(c)(5)(B), 1852(g)(5), and 1860D–
4(h) of the Social Security Act (the Act).
OMHA ensures that Medicare
beneficiaries and the providers and
suppliers that furnish items or services
to Medicare beneficiaries, as well as
Medicare Advantage Organizations
(MAOs) and Medicaid State Agencies,
have a fair and impartial forum to
address disagreements with Medicare
coverage and payment determinations
made by Medicare contractors, MAOs,
or Part D Plan Sponsors (PDPSs), and
determinations related to Medicare
eligibility and entitlement, Part B late
enrollment penalties, and incomerelated monthly adjustment amounts
(IRMAA) made by the Social Security
Administration (SSA).
The Medicare claim, organization and
coverage determination appeals
processes consist of four levels of
administrative review, and a fifth level
of review with the Federal district
courts after administrative remedies
under HHS regulations have been
exhausted. The first two levels of review
are administered by the Centers for
Medicare & Medicaid Services (CMS)
and conducted by Medicare contractors
for claim appeals, by MAOs and an
independent review entity for Part C
organization determination appeals, or
by PDPSs and an independent review
entity for Part D coverage determination
appeals. The third level of review is
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Fmt 4703
Sfmt 4703
administered by OMHA and conducted
by Administrative Law Judges. The
fourth level of review is administered by
the HHS Departmental Appeals Board
(DAB) and conducted by the Medicare
Appeals Council. In addition, OMHA
and the DAB administer the second and
third levels of appeal, respectively, for
Medicare eligibility, entitlement, Part B
late enrollment penalty, and IRMAA
reconsiderations made by SSA; a fourth
level of review with the Federal district
courts is available after administrative
remedies within SSA and HHS have
been exhausted.
Sections 1869, 1155, 1876(c)(5)(B),
1852(g)(5), and 1860D–4(h) of the Act
are implemented through the
regulations at 42 CFR part 405, subparts
I and J; part 417, subpart Q; part 422,
subpart M; part 423, subparts M and U;
and part 478, subpart B. As noted above,
OMHA administers the nationwide
Administrative Law Judge hearing
program in accordance with these
statutes and applicable regulations. As
part of that effort, OMHA has
established the OMHA Case Processing
Manual (OCPM). Through the OCPM,
the OMHA Chief Administrative Law
Judge establishes the day-to-day
procedures for carrying out adjudicative
functions, in accordance with
applicable statutes, regulations and
OMHA directives. The OCPM provides
direction for processing appeals at the
OMHA level of adjudication for
Medicare Part A and B claims; Part C
organization determinations; Part D
coverage determinations; and SSA
eligibility and entitlement, Part B late
E:\FR\FM\25NON1.SGM
25NON1
Federal Register / Vol. 80, No. 227 / Wednesday, November 25, 2015 / Notices
enrollment penalty, and IRMAA
determinations.
Section 1871(c) of the Act requires
that we publish a list of all Medicare
manual instructions, interpretive rules,
statements of policy, and guidelines of
general applicability not issued as
regulations at least every 3 months in
the Federal Register.
II. Format for the Quarterly Issuance
Notices
This quarterly notice provides the
specific updates to the OCPM that have
occurred in the 3-month period. A
hyperlink to the available chapters on
the OMHA Web site is provided below.
The OMHA Web site contains the most
current, up-to-date chapters and
revisions to chapters, and will be
available earlier than we publish our
quarterly notice. We believe the OMHA
Web site list provides more timely
access to the current OCPM chapters for
those involved in the Medicare claim,
organization and coverage
determination and entitlement appeals
processes. We also believe the Web site
offers the public a more convenient tool
for real time access to current OCPM
provisions. In addition, OMHA has a
listserv to which the public can
subscribe to receive immediate
notification of any updates to the
OMHA Web site. This listserv avoids
the need to check the OMHA Web site,
as update notifications are sent to
subscribers as they occur. If accessing
the OMHA Web site proves to be
difficult, the contact person listed above
can provide the information.
III. How To Use the Notice
This notice lists the OCPM chapters
and subjects published during the
quarter covered by the notice so the
reader may determine whether any are
of particular interest. We expect this
notice to be used in concert with the
previously published notice. The OCPM
can be accessed at https://www.hhs.gov/
omha/OMHA_Case_Processing_
Manual/.
tkelley on DSK3SPTVN1PROD with NOTICES
IV. OCPM Releases for July Through
September 2015
The OCPM is used by OMHA
adjudicators and staff to administer the
OMHA program. It offers day-to-day
operating instructions, policies, and
procedures based on statutes and
regulations, and OMHA directives.
The following is a list and description
of new and revised OCPM provisions,
and the subject matter, that have been
released in the covered 3-month period.
The full text of current OCPM
provisions is available on our Web site
VerDate Sep<11>2014
19:15 Nov 24, 2015
Jkt 238001
at https://www.hhs.gov/omha/OMHA_
Case_Processing_Manual/.
OCPM Division I: General Matters
Chapter 4, Parties. This new chapter
describes who qualify as parties to the
ALJ hearing and review process under
the applicable authorities to guide
OMHA ALJs and support staff in
ensuring those filing requests for
hearing and requests for review with
OMHA have standing to pursue appeals,
and notices and other correspondence
are sent to the appropriate individuals
and entities in accordance with the
authorities.
Chapter 5, Representatives. This new
chapter describes the roles and
responsibilities of party representatives
in the ALJ hearing and review process,
as well as the requirements to
substantiate that an individual is
authorized or appointed to act as a party
representative under the applicable
authorities.
Chapter 6, CMS and CMS Contractor
Roles. This new chapter describes the
roles and responsibilities of CMS and its
contractors in the ALJ hearing and
review process, including under what
conditions and how CMS or a contractor
may participate in the process,
including at oral hearings before OMHA
ALJs, in accordance with the applicable
authorities.
OCPM Division II: Part A/B Claim
Determinations
73783
property such as patentable material,
and personal information concerning
individuals associated with the grant
applications, the disclosure of which
would constitute a clearly unwarranted
invasion of personal privacy.
Name of Committee: National Institute of
Mental Health Special Emphasis Panel AIDS
Research Centers on Mental Health and HIV/
AIDS (P30).
Date: December 2, 2015.
Time: 12:00 p.m. to 5:00 p.m.
Agenda: To review and evaluate grant
applications.
Place: National Institutes of Health,
Neuroscience Center, 6001 Executive
Boulevard, Rockville, MD 20852, (Telephone
Conference Call).
Contact Person: David W. Miller, Ph.D.,
Scientific Review Officer, Division of
Extramural Activities, National Institute of
Mental Health, NIH, Neuroscience Center,
6001 Executive BLVD, Room 6140, MSC
9608, Bethesda, MD 20892–9608, 301–443–
9734, millerda@mail.nih.gov.
This notice is being published less than 15
days prior to the meeting due to the timing
limitations imposed by the review and
funding cycle.
(Catalogue of Federal Domestic Assistance
Program No. 93.242, Mental Health Research
Grants, National Institutes of Health, HHS)
Dated: November 18, 2015.
Carolyn A. Baum,
Program Analyst, Office of Federal Advisory
Committee Policy.
[FR Doc. 2015–29942 Filed 11–24–15; 8:45 am]
BILLING CODE 4140–01–P
Chapter 3, Procedural Screening. This
chapter has been updated to correct a
typographical error. No substantive
changes were made to the chapter.
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Dated: _November 17, 2015.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of
Medicare Hearings and Appeals.
Center for Scientific Review; Notice of
Closed Meeting
[FR Doc. 2015–30044 Filed 11–24–15; 8:45 am]
BILLING CODE 4152–01–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
National Institutes of Health
National Institute of Mental Health;
Notice of Closed Meeting
Pursuant to section 10(d) of the
Federal Advisory Committee Act, as
amended (5 U.S.C. App.), notice is
hereby given of the following meeting.
The meeting will be closed to the
public in accordance with the
provisions set forth in sections
552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
as amended. The grant applications and
the discussions could disclose
confidential trade secrets or commercial
PO 00000
Frm 00086
Fmt 4703
Sfmt 4703
National Institutes of Health
Pursuant to section 10(d) of the
Federal Advisory Committee Act, as
amended (5 U.S.C. App.), notice is
hereby given of the following meeting.
The meeting will be closed to the
public in accordance with the
provisions set forth in sections
552b(c)(4) and 552b(c)(6), Title 5 U.S.C.,
as amended. The grant applications and
the discussions could disclose
confidential trade secrets or commercial
property such as patentable material,
and personal information concerning
individuals associated with the grant
applications, the disclosure of which
would constitute a clearly unwarranted
invasion of personal privacy.
Name of Committee: Center for Scientific
Review Special Emphasis Panel;
Pathogenesis of Rare Diseases.
Date: November 20, 2015–November 20,
2016.
Time: 2:00 p.m. to 4:00 p.m.
E:\FR\FM\25NON1.SGM
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]]>Agencies
[Federal Register Volume 80, Number 227 (Wednesday, November 25, 2015)]
[Notices]
[Pages 73782-73783]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2015-30044]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
[OMHA-1502-N]
Medicare Program; Administrative Law Judge Hearing Program for
Medicare Claim and Entitlement Appeals; Quarterly Listing of Program
Issuances--July Through September 2015
AGENCY: Office of Medicare Hearings and Appeals (OMHA), HHS.
ACTION: Notice.
-----------------------------------------------------------------------
SUMMARY: This quarterly notice lists the OMHA Case Processing Manual
(OCPM) manual instructions that were published from July through
September 2015. This manual standardizes the day-to-day procedures for
carrying out adjudicative functions, in accordance with applicable
statutes, regulations and OMHA directives, and gives OMHA staff
direction for processing appeals at the OMHA level of adjudication.
FOR FURTHER INFORMATION CONTACT: Amanda Axeen, by telephone at (571)
777-2705, or by email at amanda.axeen@hhs.gov.
SUPPLEMENTARY INFORMATION:
I. Background
The Office of Medicare Hearings and Appeals (OMHA), a staff
division within the Office of the Secretary of the U.S. Department of
Health and Human Services (HHS), administers the nationwide
Administrative Law Judge (ALJ) hearing program for Medicare claim,
organization and coverage determination, and entitlement appeals under
sections 1869, 1155, 1876(c)(5)(B), 1852(g)(5), and 1860D-4(h) of the
Social Security Act (the Act). OMHA ensures that Medicare beneficiaries
and the providers and suppliers that furnish items or services to
Medicare beneficiaries, as well as Medicare Advantage Organizations
(MAOs) and Medicaid State Agencies, have a fair and impartial forum to
address disagreements with Medicare coverage and payment determinations
made by Medicare contractors, MAOs, or Part D Plan Sponsors (PDPSs),
and determinations related to Medicare eligibility and entitlement,
Part B late enrollment penalties, and income-related monthly adjustment
amounts (IRMAA) made by the Social Security Administration (SSA).
The Medicare claim, organization and coverage determination appeals
processes consist of four levels of administrative review, and a fifth
level of review with the Federal district courts after administrative
remedies under HHS regulations have been exhausted. The first two
levels of review are administered by the Centers for Medicare &
Medicaid Services (CMS) and conducted by Medicare contractors for claim
appeals, by MAOs and an independent review entity for Part C
organization determination appeals, or by PDPSs and an independent
review entity for Part D coverage determination appeals. The third
level of review is administered by OMHA and conducted by Administrative
Law Judges. The fourth level of review is administered by the HHS
Departmental Appeals Board (DAB) and conducted by the Medicare Appeals
Council. In addition, OMHA and the DAB administer the second and third
levels of appeal, respectively, for Medicare eligibility, entitlement,
Part B late enrollment penalty, and IRMAA reconsiderations made by SSA;
a fourth level of review with the Federal district courts is available
after administrative remedies within SSA and HHS have been exhausted.
Sections 1869, 1155, 1876(c)(5)(B), 1852(g)(5), and 1860D-4(h) of
the Act are implemented through the regulations at 42 CFR part 405,
subparts I and J; part 417, subpart Q; part 422, subpart M; part 423,
subparts M and U; and part 478, subpart B. As noted above, OMHA
administers the nationwide Administrative Law Judge hearing program in
accordance with these statutes and applicable regulations. As part of
that effort, OMHA has established the OMHA Case Processing Manual
(OCPM). Through the OCPM, the OMHA Chief Administrative Law Judge
establishes the day-to-day procedures for carrying out adjudicative
functions, in accordance with applicable statutes, regulations and OMHA
directives. The OCPM provides direction for processing appeals at the
OMHA level of adjudication for Medicare Part A and B claims; Part C
organization determinations; Part D coverage determinations; and SSA
eligibility and entitlement, Part B late
[[Page 73783]]
enrollment penalty, and IRMAA determinations.
Section 1871(c) of the Act requires that we publish a list of all
Medicare manual instructions, interpretive rules, statements of policy,
and guidelines of general applicability not issued as regulations at
least every 3 months in the Federal Register.
II. Format for the Quarterly Issuance Notices
This quarterly notice provides the specific updates to the OCPM
that have occurred in the 3-month period. A hyperlink to the available
chapters on the OMHA Web site is provided below. The OMHA Web site
contains the most current, up-to-date chapters and revisions to
chapters, and will be available earlier than we publish our quarterly
notice. We believe the OMHA Web site list provides more timely access
to the current OCPM chapters for those involved in the Medicare claim,
organization and coverage determination and entitlement appeals
processes. We also believe the Web site offers the public a more
convenient tool for real time access to current OCPM provisions. In
addition, OMHA has a listserv to which the public can subscribe to
receive immediate notification of any updates to the OMHA Web site.
This listserv avoids the need to check the OMHA Web site, as update
notifications are sent to subscribers as they occur. If accessing the
OMHA Web site proves to be difficult, the contact person listed above
can provide the information.
III. How To Use the Notice
This notice lists the OCPM chapters and subjects published during
the quarter covered by the notice so the reader may determine whether
any are of particular interest. We expect this notice to be used in
concert with the previously published notice. The OCPM can be accessed
at https://www.hhs.gov/omha/OMHA_Case_Processing_Manual/.
IV. OCPM Releases for July Through September 2015
The OCPM is used by OMHA adjudicators and staff to administer the
OMHA program. It offers day-to-day operating instructions, policies,
and procedures based on statutes and regulations, and OMHA directives.
The following is a list and description of new and revised OCPM
provisions, and the subject matter, that have been released in the
covered 3-month period. The full text of current OCPM provisions is
available on our Web site at https://www.hhs.gov/omha/OMHA_Case_Processing_Manual/.
OCPM Division I: General Matters
Chapter 4, Parties. This new chapter describes who qualify as
parties to the ALJ hearing and review process under the applicable
authorities to guide OMHA ALJs and support staff in ensuring those
filing requests for hearing and requests for review with OMHA have
standing to pursue appeals, and notices and other correspondence are
sent to the appropriate individuals and entities in accordance with the
authorities.
Chapter 5, Representatives. This new chapter describes the roles
and responsibilities of party representatives in the ALJ hearing and
review process, as well as the requirements to substantiate that an
individual is authorized or appointed to act as a party representative
under the applicable authorities.
Chapter 6, CMS and CMS Contractor Roles. This new chapter describes
the roles and responsibilities of CMS and its contractors in the ALJ
hearing and review process, including under what conditions and how CMS
or a contractor may participate in the process, including at oral
hearings before OMHA ALJs, in accordance with the applicable
authorities.
OCPM Division II: Part A/B Claim Determinations
Chapter 3, Procedural Screening. This chapter has been updated to
correct a typographical error. No substantive changes were made to the
chapter.
Dated: _November 17, 2015.
Nancy J. Griswold,
Chief Administrative Law Judge, Office of Medicare Hearings and
Appeals.
[FR Doc. 2015-30044 Filed 11-24-15; 8:45 am]
BILLING CODE 4152-01-P
