Grijalva v. Shalala

No. 93-711 (D. Ariz. Dec. 5, 2000); 152 F.3d 1115 (9th Cir. 1998). ; Clearinghouse Number: 49567

Description

Medicare Beneficiaries Settle Challenge to Adequacy of HMOs’ Notice of Service Denials; Fast-Track Review Process Established

Abstract

The court approved the settlement agreement in this class action lawsuit in which Medicare + Choice enrollees challenged defendant Secretary of Health and Human Services’ failure to enforce due process requirements and monitor health maintenance organizations’ denials of service to class members. Under the terms of the agreement, defendant agreed to promulgate a Notice of Proposed Rulemaking governing notice and appeal procedures for Medicare + Choice plans’ decisions to terminate coverage for provider services to enrollees. The agreement applies to skilled nursing facilities, home health agencies, and outpatient rehabilitation facilities. Plans must give enrollees four days’ advance written notice of termination; the notice must explain reasons for the action and the right to an expedited appeal. An enrollee who requests an expedited appeal will continue to receive the service until—whichever is later—the time designated for termination in the notice or the day after a negative decision on the expedited appeal. Regardless of whether the enrollee seeks the expedited appeal, other appeal procedures will remain available, although without continued coverage. The agreement also provides that defendant will issue guidance clarifying that Medicare + Choice plans’ failure in only one or two instances to comply with the new notice and appeal procedures may constitute substantial failure for purposes of imposing sanctions. The Health Care Financing Administration published the proposed rule on January 24, 2001 (66 Fed. Reg. 7593).

Additional Information

Attorney Information
Plaintiffs represented by Sally Hart Wilson, Center for Medicare Advocacy, Inc., c/o Southern Arizona Legal Aid, Inc., 64 E. Broadway Blvd., Tucson, AZ 85701-1720 ((602) 623-9464); Lenore E. Gerard, Legal Assistance to the Elderly, 1453 Mission St., Suite 500, San Francisco, CA 94103 ((415) 861-4444); Carol S. Jimenez, Center for Health Care Rights, 520 S. Lafayette Park Place, Suite 214, Los Angeles, CA 90057 ((213) 383-4519); Tom Weathered, 202 Louisburg, San Francisco, CA 94112 (415) 333-9714).
Docket Date
2000-12-05 00:00:00+00:00