Opinion ID: 616458
Heading Depth: 2
Heading Rank: 2

Heading: Urgently needed service

Text: Conahan also seeks reimbursement under 42 C.F.R. § 422.112(a)(9), which requires Medicare Advantage organizations to cover out-of-plan urgently needed services. Such services are provided when an enrollee is temporarily absent from the [Medicare Advantage] plan's service (or, if applicable, continuation) area (or, under unusual and extraordinary circumstances, provided when the enrollee is in the service or continuation area but the organization's provider network is temporarily unavailable or inaccessible ) when the services are medically necessary and immediately required (A) As a result of unforeseen illness, injury, or condition; and (B) It was not reasonable given the circumstances to obtain the services through the organization offering the [Medicare Advantage] plan. 42 C.F.R. § 422.113(b)(1)(iii) (emphasis added). Conahan contends that Kaiser's refusal to perform the surgery rendered its network temporarily unavailable or inaccessible, making Glaser's out-of-plan liver resection an urgently needed service that Kaiser was required to cover. The MAC rejected this interpretation of the regulation, concluding that Kaiser's recommendation against surgical resection of the enrollee's liver tumor did not render their provider network unavailable or inaccessible, even if this recommendation was against the enrollee's personal wishes. The MAC's conclusion is consistent with the text and history of the Medicare Advantage regulations. When it promulgated those regulations, HHS stated that the requirement to pay arises only under unusual and extraordinary circumstances, for services provided when the enrollee is in the service or continuation area, but the organization's provider network is temporarily unavailable or inaccessible, and such services are medically necessary and immediately required. We believe that examples of when this could arise would include unusual events such as an earthquake or strike, if such events impede enrollee access to care[.] 65 Fed.Reg. 40,170, 40,199 (June 29, 2000) (emphasis added). A health insurer's denial of coverage is not an extraordinary or unusual event, similar to an earthquake or labor strike. Conahan responds that earthquakes and strikes are merely examples of situations that would make a plan unavailable. However, HHS specifically rejected this broader interpretation of the proposed regulation during the notice-and-comment period. A commenter asked HHS whether the urgently needed services exception would allow beneficiaries to unilaterally obtain care out-of-plan if their [Medicare Advantage] organization did not provide the care they requested. Id. HHS replied that [t]here are other mechanisms in place to handle such situations. We may require a plan to take corrective action, where necessary, if a plan fails to provide services. In addition, services that the beneficiary believes he or she was entitled to receive from the [Medicare Advantage] organization, but that the organization denied or otherwise did not provide, may be appealed under the regulations in subpart M of part 422. Id. HHS concluded that a denial of benefits does not constitute unusual and extraordinary circumstances. This interpretation is neither plainly erroneous nor inconsistent with the regulation's plain text. Were we to accept Conahan's construction, Medicare Advantage organizations always would be required to pay for out-of-plan procedures they refuse to perform. Nothing in the regulation suggests that HHS intended such a sweeping result. Because we defer to the agency's reasonable determination that the urgently needed services exception is not triggered by a denial of coverage, Kaiser is not required to pay for the surgery.