Sec. 4. Revising beneficiary appeal rights for good faith enrollment mistakes
647 words·~3 min read·
/bill/114/s/3236/is/section-4·A research copy — for the controlling text, always check the official state or federal source. Not legal advice.
Subsection
(h)of section 1837 of the Social Security Act ( 42 U.S.C. 1395p ) is amended to read as follows: In any case in which the Secretary finds that an individual’s enrollment or nonenrollment in the insurance program established by this part or part A pursuant to section 1818 is unintentional, inadvertent, or erroneous, whether the result of the error, misrepresentation, or inaction of an officer, employee, or agent of the Federal Government or its instrumentalities, an employer, a representative of a group health plan, a State, or for any other good faith reason on the part of such individual, the Secretary shall take such action (including the designation for such individual of a special initial or subsequent enrollment period, including retroactive enrollment, with a coverage period determined on the basis thereof and with appropriate adjustments of premiums) as may be necessary to correct or eliminate the effects of such error, misrepresentation, or inaction. The failure of an individual to enroll in the insurance program established by this part or part A pursuant to section 1818 due to enrollment under a group health plan; coverage pursuant to title XXII of the Public Health Service Act, section 4980B of the Internal Revenue Code of 1986, title VI of the Employee Retirement Income Security Act of 1974, or title XIX; or enrollment under a qualified health plan offered through an Exchange established under title I of the Patient Protection and Affordable Care Act shall under this subsection absent exceptional circumstances, as determined by the Secretary. The Secretary, in consultation with the Commissioner of Social Security, shall develop and publish a formal application for requesting an action of the Secretary under paragraph
(1)to correct or eliminate the effects of an error, misrepresentation, or inaction described in such paragraph and determine and publish specific timelines for timely resolution of such a request. The Secretary shall also require that all such determinations with respect to such requests shall be reached within 15 business days of the submission of such application. All determinations shall be in writing through a standard decision notice which shall include an explanation of the reasons for the determination. The Commissioner of Social Security shall enter into contracts with independent review organizations in accordance with this subsection for the purpose of reviewing and determining individual appeals of determinations under paragraph
(3)with respect to an application submitted pursuant to paragraph
(2)relating to enrollment under part A or part B. An individual who receives an adverse determination under paragraph
(3)with respect to an application submitted pursuant to paragraph
(2)may appeal to an independent review organization designated by the Commission. Any such appeal must be sent to the independent review organization within 90 days of the date the individual received the determination to be eligible for review. The independent review organization shall review and reach a determination of the review in writing within 45 days of the receipt of any such appeal. The Secretary of the Treasury may not enter into a contract under subparagraph
(A)with an independent review organization— unless the organization has staff that has the appropriate knowledge of, and experience with, the eligibility and coordination of benefits rules and regulations under this title; and to the extent the organization is a fiscal intermediary under section 1816, a carrier under section 1842, or a Medicare administrative contractor under section 1874A. The Secretary of Health and Human Services shall provide for access by independent review organizations conducting appeal determinations under this subsection, to the database of the Coordination of Benefits Contractor of the Centers for Medicare & Medicaid Services as necessary in order to conduct the duties of such organizations to determine appeals pursuant to this subsection. . The amendment made by subsection
(a)shall take effect beginning on the date that is 6 months after the date of the enactment of this Act.
Connectionstraces to 1
Traces to 1 document
U.S. Code
Citation graph
cites case law
Sec. 4
Revising beneficiary appeal rights for good faith enrollment mistakes
Cites 1Cited by 0 across 0 sources