[Federal Register Volume 90, Number 231 (Thursday, December 4, 2025)]
[Notices]
[Pages 55869-55871]
From the Federal Register Online via the Government Publishing Office [www.gpo.gov]
[FR Doc No: 2025-21879]
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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Centers for Medicare & Medicaid Services
[CMS-4209-N]
Medicare Program; Medicare Appeals; Adjustment to the Amount in
Controversy Threshold Amounts for Calendar Year 2026
AGENCY: Centers for Medicare & Medicaid Services (CMS), Department of
Health and Human Services (HHS).
[[Page 55870]]
ACTION: Notice.
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SUMMARY: This notice announces the annual adjustment in the amount in
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, 2026.
The calendar year 2026 AIC threshold amounts are $200 for ALJ hearings
and $1,960 for judicial review.
DATES: This annual adjustment takes effect on January 1, 2026.
FOR FURTHER INFORMATION CONTACT: Natasha Franklin, (410) 786-5692.
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 medical 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 part 422, subpart M.
Specifically, Sec. Sec. 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 part 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 part
423, subparts M and U. More specifically, Sec. 423.2006 addresses 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 2026
The AIC threshold amount for ALJ hearings will rise from $190 for
CY 2025 to $200 for CY 2026, and the AIC threshold amount for judicial
review will increase from $1,900 for CY 2025 to $1,960 for CY 2026.
These amounts are based on the 96.188 percent change in the medical
care component of the CPI, which was at 297.600 in July 2003 and rose
to 583.856 in July 2025. The AIC threshold amount for ALJ hearings
changes to $196.19 based on the 96.188 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
2026 AIC threshold amount for ALJ hearings is $200.00. The AIC
threshold amount for judicial review changes to $1,961.88 based on the
96.188 percent increase over the initial threshold amount of $1,000.
This amount was rounded to the nearest multiple of $10, resulting in
the CY 2026 AIC threshold amount of $1,960.00 for judicial review.
[[Page 55871]]
C. Summary Table of Adjustments in the AIC Threshold Amounts
In the following table we list the CYs 2022 through 2026 threshold
amounts.
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CY 2022 CY 2023 CY 2024 CY 2025 CY 2026
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ALJ Hearing..................... $180 $180 $180 $190 $200
Judicial Review................. 1,760 1,850 1,840 1,900 1,960
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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), Dr. Mehmet Oz having reviewed and approved this document,
authorizes Trenesha Fultz-Mimms, who is the Federal Register Liaison,
to electronically sign this document for purposes of publication in the
Federal Register.
Trenesha Fultz-Mimms,
Federal Register Liaison, Centers for Medicare & Medicaid Services.
[FR Doc. 2025-21879 Filed 12-3-25; 8:45 am]
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