Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2025, 79294-79296 [2024-22142]

Agencies

• Centers for Medicare & Medicaid Services
• DEPARTMENT OF HEALTH AND HUMAN SERVICES

[Federal Register Volume 89, Number 188 (Friday, September 27, 2024)]
[Notices]
[Pages 79294-79296]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2024-22142]


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DEPARTMENT OF HEALTH AND HUMAN SERVICES

Centers for Medicare & Medicaid Services

[CMS-4206-N]


Medicare Program; Medicare Appeals; Adjustment to the Amount in 
Controversy Threshold Amounts for Calendar Year 2025

AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of 
Health and Human Services (HHS).

ACTION: Notice.

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SUMMARY: This notice announces the annual adjustment in the amount in

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controversy (AIC) threshold amounts for Administrative Law Judge (ALJ) 
hearings and judicial review under the Medicare appeals process. The 
adjustment to the AIC threshold amounts will be effective for requests 
for ALJ hearings and judicial review filed on or after January 1, 2025. 
The calendar year 2025 AIC threshold amounts are $190 for ALJ hearings 
and $1,900 for judicial review.

DATES: This annual adjustment takes effect on January 1, 2025.

FOR FURTHER INFORMATION CONTACT: Liz Hosna, (410) 786-4993.

SUPPLEMENTARY INFORMATION:

I. Background

    Section 1869(b)(1)(E) of the Social Security Act (the Act) 
established the amount in controversy (AIC) threshold amounts for 
Administrative Law Judge (ALJ) hearings and judicial review at $100 and 
$1,000, respectively, for Medicare Part A and Part B appeals. 
Additionally, section 1869(b)(1)(E) of the Act provides that beginning 
in January 2005, the AIC threshold amounts are to be adjusted annually 
by the percentage increase in the medical care component of the 
consumer price index (CPI) for all urban consumers (U.S. city average) 
for July 2003 to the July preceding the year involved and rounded to 
the nearest multiple of $10. Sections 1852(g)(5) and 1876(c)(5)(B) of 
the Act apply the AIC adjustment requirement to Medicare Part C/
Medicare Advantage (MA) appeals and certain health maintenance 
organization and competitive health plan appeals. Health care 
prepayment plans are also subject to MA appeals rules, including the 
AIC adjustment requirement, pursuant to 42 CFR 417.840. Section 1860D-
4(h)(1) of the Act, provides that a Medicare Part D plan sponsor shall 
meet the requirements of paragraphs (4) and (5) of section 1852(g) of 
the Act with respect to benefits, including appeals and the application 
of the AIC adjustment requirement to Medicare Part D appeals.

A. Medicare Part A and Part B Appeals

    The statutory formula for the annual adjustment to the AIC 
threshold amounts for ALJ hearings and judicial review of Medicare Part 
A and Part B appeals, set forth at section 1869(b)(1)(E) of the Act, is 
included in the applicable implementing regulations, 42 CFR 405.1006(b) 
and (c). The regulations at Sec.  405.1006(b)(2) require the Secretary 
of Health and Human Services (the Secretary) to publish changes to the 
AIC threshold amounts in the Federal Register. To be entitled to a 
hearing before an ALJ, a party to a proceeding must meet the AIC 
requirements at Sec.  405.1006(b). Similarly, a party must meet the AIC 
requirements at Sec.  405.1006(c) at the time judicial review is 
requested for the court to have jurisdiction over the appeal (Sec.  
405.1136(a)).

B. Medicare Part C/MA Appeals

    Section 1852(g)(5) of the Act applies the AIC adjustment 
requirement to Medicare Part C appeals. The implementing regulations 
for Medicare Part C appeals are found at 42 CFR 422, subpart M. 
Specifically, sections 422.600 and 422.612 discuss the AIC threshold 
amounts for ALJ hearings and judicial review. Section 422.600 grants 
any party to the reconsideration (except the MA organization) who is 
dissatisfied with the reconsideration determination a right to an ALJ 
hearing as long as the amount remaining in controversy after 
reconsideration meets the threshold requirement established annually by 
the Secretary. Section 422.612 states, in part, that any party, 
including the MA organization, may request judicial review if the AIC 
meets the threshold requirement established annually by the Secretary.

C. Health Maintenance Organizations, Competitive Medical Plans, and 
Health Care Prepayment Plans

    Section 1876(c)(5)(B) of the Act states that the annual adjustment 
to the AIC dollar amounts set forth in section 1869(b)(1)(E)(iii) of 
the Act applies to certain beneficiary appeals within the context of 
health maintenance organizations and competitive medical plans. The 
applicable implementing regulations for Medicare Part C appeals are set 
forth in 42 CFR 422, subpart M and apply to these appeals in accordance 
with 42 CFR 417.600(b). The Medicare Part C appeals rules also apply to 
health care prepayment plan appeals in accordance with 42 CFR 417.840.

D. Medicare Part D (Prescription Drug Plan) Appeals

    The annually adjusted AIC threshold amounts for ALJ hearings and 
judicial review that apply to Medicare Parts A, B, and C appeals also 
apply to Medicare Part D appeals. Section 1860D-4(h)(1) of the Act 
regarding Part D appeals requires a prescription drug plan sponsor to 
meet the requirements set forth in sections 1852(g)(4) and (g)(5) of 
the Act, in a similar manner as MA organizations. The implementing 
regulations for Medicare Part D appeals can be found at 42 CFR 423, 
subparts M and U. More specifically, Sec.  423.2006 of the Part D 
appeals rules discusses the AIC threshold amounts for ALJ hearings and 
judicial review. Sections 423.2002 and 423.2006 grant a Part D enrollee 
who is dissatisfied with the independent review entity (IRE) 
reconsideration determination a right to an ALJ hearing if the amount 
remaining in controversy after the IRE reconsideration meets the 
threshold amount established annually by the Secretary, and other 
requirements set forth in Sec.  423.2002. Sections 423.2006 and 
423.2136 allow a Part D enrollee to request judicial review of an ALJ 
or Medicare Appeals Council decision if the AIC meets the threshold 
amount established annually by the Secretary, and other requirements 
are met as set forth in these provisions.

II. Provisions of the Notice--Annual AIC Adjustments

A. AIC Adjustment Formula and AIC Adjustments

    Section 1869(b)(1)(E)(iii) of the Act requires that the AIC 
threshold amounts be adjusted annually, beginning in January 2005, by 
the percentage increase in the medical care component of the CPI for 
all urban consumers (U.S. city average) for July 2003 to July of the 
year preceding the year involved and rounded to the nearest multiple of 
$10.

B. Calendar Year 2025

    The AIC threshold amount for ALJ hearings will rise from $180 for 
CY 2024 to $190 for CY 2025, and the AIC threshold amount for judicial 
review will increase from $1,840 for CY 2024 to $1,900 for CY 2025. 
These amounts are based on the 89.529 percent change in the medical 
care component of the CPI, which was at 297.600 in July 2003 and rose 
to 564.039 in July 2024. The AIC threshold amount for ALJ hearings 
changes to $189.53 based on the 89.529 percent increase over the 
initial threshold amount of $100 established in 2003. In accordance 
with section 1869(b)(1)(E)(iii) of the Act, the adjusted threshold 
amounts are rounded to the nearest multiple of $10. Therefore, the CY 
2025 AIC threshold amount for ALJ hearings is $190.00. The AIC 
threshold amount for judicial review changes to $1,895.21 based on the 
89.529 percent increase over the initial threshold amount of $1,000. 
This amount was rounded to the nearest multiple of $10, resulting in 
the CY 2025 AIC threshold amount of $1,900.00 for judicial review.

C. Summary Table of Adjustments in the AIC Threshold Amounts

    In the following table we list the CYs 2021 through 2025 threshold 
amounts.

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                                      CY 2021         CY 2022         CY 2023         CY 2024         CY 2025
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ALJ Hearing.....................            $180            $180            $180            $180            $190
Judicial Review.................           1,760           1,760           1,850           1,840           1,900
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III. Collection of Information Requirements

    This document announces the annual adjustment in the AIC threshold 
amounts and does not impose any ``collection of information'' 
requirements as defined under 5 CFR 1320.3(c). Consequently, the notice 
is not subject to the requirements of the Paperwork Reduction Act of 
1995 (44 U.S.C. 3501 et seq.).
    The Administrator of the Centers for Medicare & Medicaid Services 
(CMS), Chiquita Brooks-LaSure, having reviewed and approved this 
document, authorizes Evell Barco, who is the Federal Register Liaison, 
to electronically sign this document for purposes of publication in the 
Federal Register.

Chyana Woodyard,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2024-22142 Filed 9-26-24; 8:45 am]
BILLING CODE 4120-01-P