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COVID-19 DECLARED A NATIONAL EMERGENCY

Under sections 201 and 301 of the National Emergencies Act (50 U.S.C. 1601 et seq )-and consistent with section 1135 of the Social Security Act (SSA), as amended (42 U.S.C. l 320b-5)-President Trump proclaimed the COVID-19 outbreak in the United States constituted a national emergency as of March 1, 2020.

Section 1135 of the SSA authorizes a temporary waiver or modification of certain Medicare, Medicaid, State Children’s Health Insurance Programs (CHIP) and Health Insurance Portability and Accountability Act (HIPAA) requirements throughout the duration of a declared public health emergency. As a result, the CMS will ensure healthcare items and services are available to meet the needs of Medicare, Medicaid and CHIP beneficiaries.

CMS Appeals & Grievances Changes

CMS Appeals and Grievances must accommodate the following changes, effective on March 21, 2020

Medicare Beneficiaries

  • Extension of time to file an appeal
  • Timeliness requirements waived for additional information to adjudicate appeals
  • Appeals must be processed, even with incomplete appointment of representation forms (communication should only be sent to beneficiary, in this circumstance)
  • Appeals must be processed utilizing available information
  • All flexibilities available in appeal processes (as if good-cause requirements are satisfied) should be utilized

Medicaid Beneficiaries

  • Temporarily suspend Medicaid fee-for-service prior-authorization requirements
  • Extend pre-existing authorizations for each beneficiary-those witr prior authorization-through end of public health emergency
  • State Fair-hearing Requests and Appeal Timelines
    • CMS approves a waiver under section 1135 that allows enrollees more than 90 days-up to an additional 120days-for eligibility or fee-for-service appeal to request a fair hearing
    • Timeframe modification for managed-care entities to resolve appeals under 42 C.FR. §438.408(f)(l) before enrollee may request a State Fair Hearing to no less than one d

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