05-12468. Office of Medicare Hearings and Appeals; Statement of Organization, Functions, and Delegations of Authority

Part A. Office of the Secretary, of the Statement of Organization, Functions, and Delegations of Authority for the Department of Health and Human Services, Part A, as last amended at 69 FR 51679-51680, dated August 20, 2004, and Chapter AA, Immediate Office of the Secretary, as last amended at 69 FR 51679-51680, dated August 20, 2004, are being amended to establish a new Chapter AK, the Office of Medicare Hearings and Appeals (OMHA) within the Office of the Secretary. This new Chapter is being created as a result of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA), under which the functions of Administrative Law Judges (ALJs) responsible for hearing cases under title XVIII of the Social Security Act (and related provisions in title XI of such Act) are transferred from the Social Security Administration to the Department of Health and Human Services. The changes are as follows:

I. Under Part A, Chapter AA, Section AA, Section AA.10 Organization, insert the following: “Office of Medicare Hearings and Appeals (OMHA)”

II. Under Part A, establish a new Chapter AK, “Office of Medicare Hearings and Appeals (OMHA)” to read as follows:

Section AK.00 Mission

Section AK.10 Organization

Section AK.20 Functions

Section AK.00 Mission. The Office of Medicare Hearings and Appeals (OMHA), under direct delegation from the Secretary of the Department of Health and Human Services, administers the nationwide hearings and appeals programs for the Medicare Program. The ALJs within the Office of Medicare Hearings and Appeals issue the final decisions of the Secretary, except for decisions reviewed by the Medicare Appeals Council, on hihgly complex appealed determinations involving Medicare Part A, B, C, and D. OMHA provides the basic mechanisms through which individuals and organizations dissatisfied with Medicare determinations affecting their rights in the Medicare program under the Social Security Act may obtain a hearing on these determinations. OMHA directs four field offices staff with Administrative Law Judges (ALJs) who conduct impartial “de novo” hearings and made decisions on appealed determinations involving Medicare appeals, as well as a Headquarters office.

Section AK.10 Organization: The Office of Medicare Hearings and Appeals (OMHA) is under the direction of the Chief Administrative Law Judge, who reports directly to the Secretary, OMHA consists of the following components.

• Office of Medicare Hearings and Appeals, Immediate Office (AKA) Medicare Hearing and Appeals Field Offices (AKB1-4).
• Medicare Hearing and Appeals Field Offices (AKB1-4).

—Medicare Hearings and Appeals Mid-Atlantic Field Office—Rosslyn, VA (AKB1)

—Medicare Hearings and Appeals Mid-West Field Office—Cleveland, OH (AKB2)

—Medicare Hearings and Appeals Western Field Office—Irvine, CA (AKB3)

—Medicare Hearings and Appeals Southern Field Office—Miami, FL (AKB4)

Section AK.20 Functions

A. The Office of Medicare Hearings and Appeals Immediate Office (AK): The Office of Medicare Hearings and Appeals Immediate Office (OMHA/IO) is headed by the Chief Administrative Law Judge (CALJ), who reports directly to the Secretary. The Chief Administrative Law Judge (CALJ) is responsible for carrying out OMHA's mission and implementing authorities granted to the ALJs by the Secretary. The CALJ is responsible for: (a) planning, directing, managing, coordinating, and maintaining the integrity of the field office hearings and appeals system by directing the planning, development, and coordination of regulations, policies and procedures governing the hearings and appeals program under the applicable statutes; (b) maintaining a hearings and appeal system which is impartial and which supports the tenets of fairness and equal treatment under the law; and (c) ensuring adherence to statutory procedures, time limits, and other procedural requirements of the Administrative Procedure Act, Medicare law and applicable HHS regulations. The CALJ provides executive leadership to, and administrative and management support functions for, the field offices which hold hearings and render decisions under the Social Security Act, and in that capacity establishes specific objectives, standards, and management and program policies with respect to the field office responsibilities.

The Executive Director (ED) of OMHA/IO, reports to the CALJ, and is responsible for all operational matters and executive and managerial oversight in support of the mission of the office, with the exception of areas directly involving the conduct of adjudicatory hearings and the rendering of fair and impartial decisions ensuing from those hearings.

B. Medicare Hearings and Appeals Field Offices (AB1-4). The Field Offices are headed by a Managing Administrative Law Judge (MALJ) who reports directly to the CALJ. The Managing Administrative Law Judge (MALJ) acts on behalf of the CALJ at the respective field office location on all matters involving the hearing process, and is directly responsible for the effective execution of the hearings process within the field location. The MALJ is responsible for: (a) Providing direction, leadership, management and guidance to the field office staff, including Administrative Law Judges and their staffs, and weighted workload attorneys; (b) field office implementation of policies, goals, objectives, and procedures pertaining to the hearings process, and formulating policies, goals, and objectives for the ALJs and support staff in their field office; (c) planning, organizing and administering field operations for scheduling and conducting independent and impartial hearings on appealed determinations involving adjudicatory hearings for authorities delegated to the ALJs by the Secretary; (d) developing and recommending OMHA action with respect to allegation of unfair hearings within the field operations; (e) upon request by ALJs providing advice and guidance in matters related to adjudicating cases under the provisions of the Social Security Act; and (f) conducting adjudicatory hearings under authorities delegated to the ALJs by the Secretary.

The Hearing Office Manager (HOM), who reports to the Managing Administrative Law Judge (MALJ), is responsible for the day-to-day management and operations of the field office, with the exception of areas directly involving the conduct of adjudicatory hearings and the rending of fair and impartial decisions ensuing from those hearings. The Hearing Office Manager is responsible for: (a) Office management, including workload, personnel, and overall resource management; (b) executing and making critical evaluations and necessary revisions of applicable field office objectives, policies, practices, and procedures; (c) reviewing hearing practices and procedures to detect trends, training needs, and operational problems; (d) justifying the financial requirements needed to carry out the hearings in the field office; and (e) coordinating operation and administrative activities with OMHA/IO.

Supervisory Administrative Law Judges within the Field Offices are responsible for conducting adjudicatory hearing for authorities granted to the ALJs by the Secretary. Supervisory Administrative Law Judges are also responsible for supervising staff attorney(s), paralegal(s), and hearing clerk(s).

Attorneys and Paralegals are responsible for researching appeals; reviewing and evaluating case files; preparing briefs and transcripts; assisting in pre-hearing proceedings; drafting decisions; and, providing assistance to Administrative Law Judges.

Hearing Clerks are responsible for assisting in the hearings and appeals process. Administrative support staff, under direction of the Hearing Office Manager, provide support services to hearings operations staff, and the ALJs.

Dated: June 15, 2005.

Michael O. Leavitt,

Secretary.