Patients with Medicare Advantage (MA) Insurance Information for Comprehensive Outpatient Rehabilitation Facilities (CORFs)

The following information is in regard to a new Medicare regulation pertaining to the rights of MA enrollees. The regulation, effective January 1, 2004, addresses MA organizations' termination of service coverage. Termination of service coverage is an MA organizational decision to discontinue coverage of services being provided to an MA enrollee. This information is applicable to patients only with MA insurance who are receiving CORF services.

Prior to an MA organization terminating coverage of a service, the CORF will be required to deliver an advance notice to the MA patient. The intent of an advance notice is to inform the patient of an end date for MA coverage of the health care service being provided, allowing time for an appeal if the patient disagrees with the coverage end date. Instructions for use of the "Notice of Medicare Non-Coverage." Because of the advance notice, if an appeal were unsuccessful, the most the patient would be financially liable for would be one day of services.

Appeals will be conducted by the Medicare QIO, which will require that a copy of the enrollee's medical record be provided to them no later than close of business of the day the request for an appeal was made. Click here for a Fast Track Appeal Timeline.

Notice of Medicare Message of Non-Coverage (Advance Notice)

The Centers for Medicare & Medicaid Services (CMS) require CORFs deliver the advance notice "Notice of Medicare Non-Coverage." This is a standardized, largely generic notice to be given to each MA enrollee prior to the MA organization terminating coverage of a health care service. The notice contains only two patient-specific elements: the patient's name and the date services will end. These advance notices provide standardized information on a patient's appeal rights and instructions on how to initiate an appeal.

CMS believes that CORFs are in a better position than MA organizations to carry out routine delivery of service termination notices to their patients. The CORF will deliver the advance notice and, if the patient disagrees with the termination services, the MA organization will follow up with a detailed notice.

The CORF's obligation to give an advance termination notice to the patient exists even if the CORF or attending physician disagrees with the MA organization that services should terminate. The MA organization's decision to end services is not an indication that the CORF necessarily agrees that services should end, but it is necessary to ensure that the patient has the opportunity to appeal the MA organization's decision.

Compliance

CORFs will be obligated to comply with notice requirements through the amendment of the Code of Federal Regulations (42CFR489.27(b)) provider agreement regulations, as well as through their contractual arrangements with MA organizations. MA organizations may choose to delegate to the CORF the responsibility for discharge and termination decisions, and for the delivery of detailed notices in disputed termination cases. MA organizations also may offer incentives to CORFs for compliance with these responsibilities, or penalties for non-compliance, through their private contractual arrangements. However, consistent with the Code of Federal Regulations (42CFR422.502(i)), MA organizations remain ultimately responsible for such delegated requirements.

Issuance of Notice of Medicare Non-Coverage

The advance notice may be given as soon as the termination date is known; however, it must be given no later than two days before the proposed end of the services. When the span of time between services exceeds two days, the patient is to be notified no later than the next to last time the services are to be furnished.

Example:
An MA enrollee has been receiving physical therapy services each Monday and Thursday. The MA organization notifies the CORF that coverage will be terminated, with a Friday effective date. The CORF must issue a notice no later than Monday (the next to last time the service is to be furnished).

A patient may waive the right to continued services if he or she agrees with being discharged sooner than two days after receiving the notice.

Example:
A physician writes an order stating a patient no longer requires CORF services on a Tuesday; however, the advance notice has been issued listing a termination date of Thursday. If the patient agrees with the doctor's order, he or she may decline services beginning Tuesday. The advance notice simply informed the patient that MA coverage would end Thursday.

The patient must sign that he or she received the notice. If a patient refuses to sign the notice, the CORF will annotate its copy of the notice to indicate refusal, and the date of the refusal is to be considered the date of receipt of the notice.

In addition, the patient must be competent to sign the notice. An incapacitated patient is not able to comprehend his or her rights and, therefore, could not validly "receive" the notice. This situation could be remedied through the use of an authorized representative under Federal or State law.

Example:
If a patient with a diagnosis of senile dementia signed the advance notice, it would not be considered valid. The CORF should have been aware of the patient's inability to accept delivery of the notice based on typical activities that take place during the course of treatment.

For more information, contact:

New Mexico Medical Review Association (NMMRA)
5801 Osuna Road NE, Suite 200
Albuquerque, NM 87109-2587
(505) 998-9898 (in Albuquerque)
1-800-663-6351 (toll-free)