It’s never too soon to explore how to extend your income and begin to plan for a comfortable retirement, which not only means fiscal health, but emotional well-being as well.  Some tips include:

Get Fit

Before you step out of the workforce, and potentially away from your employer-mandated health insurance, make sure you are in good health. Get checked up and signed off by your doctor on any issues you may have and get the ‘a-okay” before embarking on your retirement travel or activities.

Hobbies, Interests and Passions

Working full-time doesn’t leave much time to pursue what might else really interest you. But when you are retired or semi-retired, the extra time and energy may allow you to pursue your other dreams. Now is the time to travel, learn a foreign language or musical instrument, sign up for volunteer work or launch the teaching career by offering courses at the local community center.

Easy Does It

Speaking of ‘semi-retired” don’t think you have to stop all work, all at once. Many almost-ready-to-retire workers start by negotiating a downgrade in work time, from full-time to half-days, or a three-day week.  Approach the new scheduling options as a way to make things work best for you and your employer. Transition the new employee into your old role, stay on as a consultant – just be sure to work out the details of your proposal before you approach your employer.

Get Social

Plan to feel a little lost when you are no longer seeing coworkers on a regular basis. Now is the time to become more active in your community and find ways to connect with others. Chances are, there are numerous organizations and groups where you can make a contribution.

Thomas D. Begley, III, CELA is a New Jersey elder law attorney with The Begley Law Group. To contact a New Jersey estate planning, special needs planning, or elder law attorney, call 1.800.533.7227 or visit http://www.begleylawyer.com.

It’s that time of year again – vacation season!  The pre-vacation To Do list keeps getting longer and longer: pack a swimsuit, stop the mail for the week, ask neighbors to water the flowers, set up transportation to the airport.  But before you leave for some fun in the sun, add one more item to your To Do list – review your estate plan.  Sometimes we become so busy getting ready for relaxation and family time that we overlook the reality that with increased travel comes increased risk. Unfortunately, travel accidents occur every day, and it would be remiss to neglect to ensure that your affairs are in order before leaving for your trip.

Parents of Minor Children

It is essential that couples with young children have estate plans in place to deal with the unlikely, but possible, scenario that both parents pass away, leaving their children orphaned.

Name preferred guardians.

In your will, you have the opportunity to name the individuals whom you would wish to act as a legal guardian of your child(ren) in the event that you and your spouse have both passed away.  It is important to note that naming someone does not guarantee that the individual will definitely act as guardian of your child(ren).  That individual must accept the guardianship.  Further, a court has the authority to name another individual if there is an appropriate reason to do so.

Create trusts for minors’ inheritances.

A second important action for parents of minors is to provide in their wills that any inheritance received by a minor be held in trust.  The parents must also choose and name a trustee to administer these funds until the child reaches a specified age.  An individual or a corporate trustee may be named; however, many corporate trustees will refuse to accept trusteeship of trust funds under certain amounts.

Successor Executors and Trustees

Many people, whether or not they have minor children, will name only one executor, typically a spouse.  It is essential to name successor executors because it is nearly inevitable that one spouse will predecease the other. Once the surviving spouse passes away, someone must be named to administer that estate.  Further, a successor executor must be in place in case the primary executor, while still alive, becomes incapacitated or unable to fulfill his or her executorial duties.  We typically recommend naming at least two successor executors to provide for these contingencies.

As noted previously, when setting up a trust, it is essential to name a trustee.  As with executors, it is necessary to name one or more successor trustees.

Advance Directives and Powers of Attorney

Before leaving for summer vacation, you should also make sure that your advance directives and powers of attorney are up to date.  These documents operate while you are still alive, but you are incapacitated and unable to make your own decisions.  In the advance directive, you should clarify your preferences for the provision or withdraw of life-sustaining treatment.  In the healthcare power of attorney and general durable power of attorney, you should name an agent, as well as successor agents, to act in your stead if you are unable to do so.

Update Existing Documents

Even if you already have documents in place, review them.  Circumstances change.  Children and grandchildren are born, elderly relatives pass away, or individuals may develop disabilities. You may have purchased a vacation home in another state or received a large inheritance.  All of these life changes, as well as changes in laws, affect your estate plan.  Documents ought to be reviewed annually to ensure that everything is in order… then, it’s time to enjoy that vacation!

Susan M. Green is a New Jersey estate planning attorney with The Begley Law Group. To contact a New Jersey estate planning, special needs planning, or elder law attorney, call 1.800.533.7227 or visit http://www.begleylawyer.com.

Many fundraisers are held by individuals who are seeking to help a friend or stranger in need, but who do not have experience with the stringent requirements that the law places on such efforts. The following provides a brief overview of such requirements in New Jersey and Pennsylvania.

New Jersey and Pennsylvania Statutory Requirements for Registration

The New Jersey Charitable Registration and Investigation Act (N.J.S.A. §45:17A-18 through -40) defines a charitable organization as “any person determined by the federal Internal Revenue Service to be a tax exempt organization pursuant to section 501(c)(3)…or any person who is, or holds himself out to be, established for any benevolent, philanthropic, human, social welfare, public health, or other eleemosynary purpose, or for the benefit of law enforcement personnel, firefighters or other persons who protect the public safety, or any person who in any manner employs a charitable appeal as the basis of any solicitation, or an appeal which has a tendency to suggest there is a charitable purpose to any such solicitation.” N.J.S.A. §45:17A-20.

Similarly, the Pennsylvania Solicitation of Funds for Charitable Purposes Act (10 Pa.C.S. §162.1 through .22) defines a charitable organization as “any person granted tax exempt status under section 501(c)(3)…or any person who is or holds himself out to be established for any charitable purpose or any person who in any manner employs a charitable appeal as the basis of any solicitation or an appeal which has a tendency to suggest there is a charitable purpose to any solicitation.” 10 Pa.C.S. §162.3.

Unless a charitable organization is exempt from registration requirements, that organization must file a registration statement with the Attorney General in New Jersey. Exempt entities include religious institutions and charitable organizations that receive gross contributions that do not exceed $10,000 in a fiscal year if all of the functions of the organization are carried on by “volunteers, members, officers or persons who are not compensated for soliciting contributions.” N.J.S.A. §45:17A-26. Short form registration is required for charitable organizations that receive gross contributions less than $25,000 in a fiscal year and if all functions are carried out by those individuals described above. Short form registration will also be required for people who request contributions for relief of a specified individual if all of the contributions, with no deductions, are turned over to the named beneficiary. N.J.S.A. §45:17A-25. Other organizations are required to file long form registration, which is more complex. N.J.S.A. §45:17A-24.

In Pennsylvania, charitable organizations that receive contributions of $25,000 or less annually and that do not compensate solicitors are exempt from registration requirements. 10 Pa.C.S. §162.6. Short form registration is required in Pennsylvania in a number of situations, including but not limited to:

1. An individual or charitable organization that accepts contributions for a specific individual if all of the contributions, without any deductions, are given to the beneficiary and held in trust subject to 20 Pa.C.S. §71.

2. Charitable organizations whose fundraising activities are carried on by volunteers, officers, members or permanent employees and that do not receive contributions in excess of $25,000 in a fiscal year, if no part of the assets or income inures to the benefit of or is paid to any officer or member, professional fundraising counsel, professional solicitor or commercial coventurer.

3. Charitable organizations described in number 2 above which do not receive contributions in excess of $100,000 in a fiscal year if no part of the assets or income inures to the benefit of or is paid to a professional solicitor. 10 Pa.C.S. §162.7.

Other organizations will be required to file long form registration.

In both New Jersey and Pennsylvania, an independent paid fundraiser or paid solicitor is an individual who is compensated for requesting contributions on behalf of a charitable organization. This does not include an employee, a bona fide salaried officer, or a volunteer, nor does it include an accountant, attorney or banker who advises a person to make a charitable contribution. N.J.S.A. §45:17A-20; 10 Pa.C.S. §162.3.

Registration Fees and Penalties

Registration fees in New Jersey and Pennsylvania are typically nominal and increase based on the amount of funds that a registering organization or individual grosses annually. N.J.S.A. §45:17A-40; 10 Pa.C.S. §162.5(p).

In both states, after notice and the opportunity for a hearing, penalties may be assessed for reasons of a false filing, violations of the Acts, engaging in dishonesty, conviction of a criminal offense in connection with activities regulated under the Act, refusal to produce records, etc. In New Jersey, a civil penalty of $20,000 will be assessed for each further violation of the Act. N.J.S.A. §45:17A-33. In Pennsylvania, remedies include revocation of tax exempt status or the issuance of a cease and desist order. Civil fines cannot exceed $1,000 for each act of wrongdoing, and additional penalties of $100 per day may be charged as long as the violation continues. Criminal penalties may also be assessed, if necessary. 10 Pa.C.S. §162.17-.19.

Susan M. Green is a New Jersey estate planning attorney with The Begley Law Group. To contact a New Jersey estate planning, special needs planning, or elder law attorney, call 1.800.533.7227 or visit http://www.begleylawyer.com.

Crisis and Kindness

In times of crisis, people often show just how caring humanity can be. Major humanitarian relief efforts respond to large-scale natural and unnatural disasters. Strangers donate time and money to individuals injured in tragic accidents. Often, the first instinct when you learn that someone is hurt is to give money. Unfortunately, unbeknownst to the donor, this kind and selfless act can have devastating ramifications for the injured individual and his or her family.

If the injured individual or a family member is receiving means-tested government benefits, such as SSI or Medicaid, any extra income or assets could potentially lead to disqualification for benefits. Further, some people might hold a fundraiser in an effort to assist the injured party without a thorough understanding of the laws regulating them. Most dangerous are those “lone rangers” who hold fundraisers or collect money without notifying the family or providing the family with an opportunity to ensure that the proper safeguards are in place.

Important Preliminary Considerations

Tax Treatment of Gifts

Under 26 U.S.C. §102(a), gifts are specifically excluded from the definition of income. As such, gifts are likely not tax-deductible to donors. Additionally, the donor may be taxed if the amount given to an individual exceeds the annual limit, currently $13,000 in 2012.

However, gifts that are to or for the use of qualified charitable organizations are tax deductible. The charity must have unfettered control of the ultimate disposition of funds, and the donor’s intent must be to benefit the charity, not a specific individual. If the contribution is to a specific individual, it does not qualify as a charitable deduction. 26 U.S.C. §170(a), (c); Rev. Rul. 79-81.

Intent of Donor: Who is the Beneficiary?

Sometimes it can be difficult to determine the proper beneficiary of a gift. A donor may intend to benefit the disabled person/injured individual, the family of the disabled person, or the organization raising the funds. The owner is the individual who has title to the proceeds of the payment. The easiest way to make clear the intent is for the donor to contribute using a check. The “name on the check” rule operates to determine the intended beneficiary. However, it can be much more difficult to determine the intended beneficiary of a cash payment.

When are Funds Considered Received?

When funds are considered received may seem simple enough, but the timing can have a major effect on individuals already receiving benefits. According to the Social Security Administration’s Program Operations Manual System (POMS), income is counted at the earliest of the following:
1. When the payment is received,
2. When the payment is credited to the beneficiary’s account, or
3. When the payment is set aside for the beneficiary’s use.
POMS SI 00810.030(A). It may be difficult to determine when income is counted for a special needs trust. The Social Security Administration may take the position that receipt occurs when the funds are held in a separate account, pending the establishment and funding of a special needs trust.

Disposition of Funds

Depending on the amount of money that is raised, there are several alternatives for properly utilizing the funds. If the recipient of the money is a minor, it may be necessary to establish a guardianship and place the funds under the supervision of the court. If an individual needs to obtain public benefits, he or she could spend down the money that is received, including the payment of debts. If the funds received are significant, and the beneficiary is disabled, it may be beneficial to establish a special needs trust.

Definition of Disability as Determined by Social Security Administration

If you are considering establishing a special needs trust, it is necessary to determine whether the individual is considered disabled within the definitions of the Social Security Administration (SSA).

For adults, disability is defined by SSA as the inability to engage in any substantial gainful activity (SGA) by reason of any medically determinable physical or mental impairment(s) which can be expected to result in death or which has lasted or can be expected to last for a continuous period of not less than 12 months.

A child under age 18 will be determined to be disabled if he or she has a medically determinable physical or mental impairment or combination of impairments that causes marked and severe functional limitations, and that can be expected to cause death or that has lasted or can be expected to last for a continuous period of not less than 12 months.

A “medically determinable impairment” is one that results from anatomical, physiological, or psychological abnormalities which can be shown by medically acceptable clinical and laboratory diagnostic techniques. The impairment must be established by medical evidence.

Establishing a Special Needs Trust

If a special needs trust is appropriate, there are several important considerations to be made. First, termination language should be included in the trust to provide for the possibility that the disability is later resolved. When funds are payable to or donated in cash to a disabled beneficiary, a third party trust is not a viable option. If the funds are not that significant, but disqualification for benefits is a concern, a pooled trust can be considered. For a pooled trust, funds of others who are similarly situated are pooled together for investment purposes; however, each individual has a separate sub account and receives monthly statements of the account activity.

An individual self-settled special needs trust (also known as a d4A trust) may be established when donated funds are identified as clearly meant for the benefit of the beneficiary with the disability, there is no question as to the donor’s intent, any alternatives to a special needs trust would not meet the beneficiary’s needs, personal funds are not anticipated to be sufficient for future expenses, and the amount would attract a professional trustee. This type of trust will be subject to a Medicaid payback provision.

Charitable Organizations

Establishment

There are two tests for measuring whether a charitable organization can obtain tax-exempt status. The organizational test provides that an organization must be for one or more exempt purposes. 26 C.F.R. §1.501(c)(3)-1(a). The operational test provides that an organization is exempt only if it engages primarily in activities that accomplish an exempt purpose. 26 C.F.R. §1.501(c)(3)-1(c).

New Jersey Statutory Requirements for Registration

The New Jersey Charitable Registration and Investigation Act (N.J.S.A. §45:17A-18 through -40) defines a charitable organization as “any person determined by the federal Internal Revenue Service to be a tax exempt organization pursuant to section 501(c)(3)…or any person who is, or holds himself out to be, established for any benevolent, philanthropic, human, social welfare, public health, or other eleemosynary purpose, or for the benefit of law enforcement personnel, firefighters or other persons who protect the public safety, or any person who in any manner employs a charitable appeal as the basis of any solicitation, or an appeal which has a tendency to suggest there is a charitable purpose to any such solicitation.” N.J.S.A. §45:17A-20.

Unless a charitable organization is exempt from registration requirements, that organization must file a registration statement with the Attorney General in New Jersey. Exempt entities include religious institutions and charitable organizations that receive gross contributions that do not exceed $10,000 in a fiscal year if all of the functions of the organization are carried on by “volunteers, members, officers or persons who are not compensated for soliciting contributions.” N.J.S.A. §45:17A-26. Short form registration is required for charitable organizations that receive gross contributions less than $25,000 in a fiscal year and if all functions are carried out by those individuals described above. Short form registration will also be required for people who request contributions for relief of a specified individual if all of the contributions, with no deductions, are turned over to the named beneficiary. N.J.S.A. §45:17A-25. Other organizations are required to file long form registration, which is more complex. N.J.S.A. §45:17A-24.

Further, in New Jersey, it is unlawful to act as a solicitor of an independent paid fund raiser unless you have registered with the Attorney General. The laws of New Jersey define an independent paid fund raiser as “any person…who for compensation performs for or on behalf of a charitable organization any service in connection with which contributions are or will be solicited…” N.J.S.A. §45:17A-20. This does not include a bona fide salaried officer, employee, or volunteer, nor does it include an attorney, accountant or banker who advises a person to make a charitable contribution. Id. Prior to soliciting a contribution, an independent paid fund raiser or a charitable organization shall clearly and conspicuously disclose any information as prescribed by the rules adopted by the Attorney General. N.J.S.A. §45:17A-28. Solicitation is defined in New Jersey as the “request, directly or indirectly, for money, credit, property, financial assistance, or another thing of any kind or value which will be used for a charitable purpose or benefit a charitable organization.” N.J.S.A. §45:17A-20. It is of course necessary to keep complete and accurate records.

Pennsylvania Statutory Requirements for Registration

The Pennsylvania Solicitation of Funds for Charitable Purposes Act (10 Pa.C.S. §162.1 through .22) defines a charitable organization as “any person granted tax exempt status under section 501(c)(3)…or any person who is or holds himself out to be established for any charitable purpose or any person who in any manner employs a charitable appeal as the basis of any solicitation or an appeal which has a tendency to suggest there is a charitable purpose to any solicitation.” 10 Pa.C.S. §162.3.

In Pennsylvania, charitable organizations that receive contributions of $25,000 or less annually and that do not compensate solicitors are exempt from registration requirements. 10 Pa.C.S. §162.6. Short form registration is required in Pennsylvania in a number of situations, including but not limited to:
1. An individual or charitable organization that accepts contributions for a specific individual if all of the contributions, without any deductions, are given to the beneficiary and held in trust subject to 20 Pa.C.S. §71.
2. Charitable organizations whose fundraising activities are carried on by volunteers, members, officers or permanent employees and that do not receive contributions in excess of $25,000 in a fiscal year, if no part of the assets or income inures to the benefit of or is paid to any officer or member, professional fundraising counsel, professional solicitor or commercial coventurer.
3. Charitable organizations described in number 2 above which do not receive contributions in excess of $100,000 in a fiscal year if no part of the assets or income inures to the benefit of or is paid to a professional solicitor. 10 Pa.C.S. §162.7.
Other organizations will be required to file long form registration. Again, it is extremely important to keep accurate records.

In Pennsylvania, solicitation is defined as, “any direct or indirect request for a contribution on the representation that such contribution will be used in whole or in part for a charitable purpose…” 10 Pa.C.S. §162.3. A professional solicitor in Pennsylvania is “any person who is retained for financial or other consideration by a charitable organization to solicit…contributions for charitable purposes…A bona fide salaried officer or regular, nontemporary employee of a charitable organization shall not be deemed to be a professional solicitor provided that the individual is not employed or engaged as professional fundraising counsel or as a professional solicitor by any other person.” Id.

Registration Fees

In New Jersey, there is no annual fee for those organizations filing the short form registration and grossing less than $10,000 in a fiscal year. For organizations filing short form registration, but grossing more than $10,000 in a fiscal year, the annual fee is $30. The fee for organizations utilizing long form registration and grossing less than $100,000 per year is $60. For organizations filing long form registration and grossing more than $100,000 per year, the fee is $250. N.J.S.A. §45:17A-40.

In Pennsylvania, there is a $15 annual fee for short form registration filing or for organizations grossing less than $25,000 in a fiscal year. The fee for organizations grossing between $25,000 and $100,000 in a fiscal year is $100. The fee for organizations grossing $100,000 to $500,000 in a fiscal year is $150, and there is a $250 fee for organizations grossing more than $500,000 each year. 10 Pa.C.S. §162.5(p).

Penalties

In New Jersey, after notice and the opportunity for a hearing, the Attorney General may revoke or suspend any registration for reasons of a false filing, violations of the New Jersey Charitable Registration and Investigation Act, engaging in dishonesty, conviction of a criminal offense in connection with activities regulated under the Act, etc. A civil penalty of $20,000 will be assessed for each further violation of the Act. N.J.S.A. §45:17A-33.

In Pennsylvania, penalties will be assessed for violations following notice and a hearing. Violations may include violations of the Pennsylvania Solicitation of Funds for Charitable Purposes Act, refusal to produce records, and material false statements. Remedies include revocation of tax exempt status or the issuance of a cease and desist order. Civil fines cannot exceed $1,000 for each act of wrongdoing, and additional penalties of $100 per day may be charged as long as the violation continues. Criminal penalties may also be assessed, if necessary. 10 Pa.C.S. §162.17-.19.

Conclusion

The laws regulating fundraisers and charitable organizations are intricate. Statutes in New Jersey and Pennsylvania each have slightly different nuances. The most prudent action one can take is to bring together a disciplinary team who will work together to navigate the legal system.

Susan M. Green is a New Jersey estate planning attorney with The Begley Law Group. To contact a New Jersey estate planning, special needs planning, or elder law attorney, call 1.800.533.7227 or visit http://www.begleylawyer.com.

Levels of Appeal
Regional Office Appeal
Once the regional VA office issues a determination, in the form of an award letter, the application can request reconsideration of the decision. The claimant should provide the VA with any other relevant evidence. For example, if the VA did not deduct unreimbursed medical expenses, such medical expenses can be submitted with a request for reconsideration.

If this request for reconsideration is unsuccessful, the application can request an evidentiary hearing at the regional office by filing a notice of disagreement, typically in the form of a letter. [] This notice of disagreement must be filed within one year from the date of the award letter. [] Upon receipt of this notice of disagreement, the VA will issue a statement of the case, which is the VA’s official notice detailing the basis for its decision. This statement of the case includes a summary of all evidence that the VA received and considered, applicable laws and regulations, and the reason for the determination.

The applicant must then file a substantive, or formal, appeal with the regional office within 60 days of the date of the statement of the case or within one year of the date on the original award letter, whichever is later. [] This appeal is filed on VA Form 9. At this level of appeal, most applicants are represented by service organizations, but a recent change in the law now allows attorneys to represent applicants and to receive payment for services after the notice of disagreement has been filed with the VA.

Board of Veteran’s Appeals
Appeals to the regional office are usually unsuccessful, so the applicant can then appeal to the Board of Veteran’s Appeals (BVA). The BVA has jurisdiction to review all questions of fact and law that are on appeal of a claim filed by a veteran, a dependent of a veteran, or a survivor of a veteran. [] This review is de novo, and new evidence can be presented. []

3. U.S. Court of Appeals for Veterans’ Claims (CAVC)
Upon receipt of an unsatisfactory BVA decision, the applicant can appeal to the U.S. Court of Appeals for Veterans’ Claims (CAVC). The CAVC has exclusive jurisdiction to review BVA decisions. [] The notice of appeal to the CAVC must be filed within 120 days of the BVA decision and must comply with Rule 3(c) of the Court Rules of Practice and Procedure. [] The CAVC reviews the administrative record created at the BVA, so no new evidence is presented. Very few cases are taken to the CAVC, but there is a high success rate of those that come before the CAVC.

U.S. Court of Appeals for the Federal Circuit
The Federal Circuit has nationwide jurisdiction over a variety of matters, including veterans’ benefits. The appellant must file a Form 4, and the appeal must be filed with the district clerk within 30 days after the judgment or order appealed from is received at the clerk’s office. [] Often, VA cases decided by the Federal Circuit become precedent for future VA cases.

Begley Law Group, PC has attorneys who can provide advice and strategies for you to qualify for these valuable benefits, even on appeal. Each of the Partners at Begley Law Group, PC is an Accredited Attorney by the Department of Veterans Affairs (VA) and can assist you in Veterans Planning. Begley Law Group is a family-oriented law firm with a century-plus of combined attorney experience. To learn more, go to www.begleylawgroup.com or call 800-533-7227.

Begley Law Group, P.C.
509 South Lenola Road, Building 7
Moorestown, NJ 08057

Thomas D. Begley, III, CELA is a New Jersey elder law attorney with The Begley Law Group. To contact a New Jersey estate planning, special needs planning, or elder law attorney, call 1.800.533.7227 or visit http://www.begleylawyer.com.

Stages of Review
Coverage Determination
A coverage determination is issued by the drug plan. It may be requested by a beneficiary, the beneficiary’s appointed representative, or a prescribing physician. The drug plan must issue a coverage determination as expeditiously as an enrollee’s health requires, but no later than 72 hours (for a standard request, including when the beneficiary already paid for the drug) or 24 hours (if expedited because the standard timeframe would jeopardize the life or health of the beneficiary or the beneficiary’s ability to regain maximum function).

An “exception” is a type of coverage determination. It gets the enrollee into the appeals process. Beneficiaries may request an exception to cover non-formulary drugs, to waive utilization management requirements, and to reduce cost-sharing for a formulary drug. There is no exception for specialty drugs or to reduce the costs of tiered co-pay for generic drugs. A doctor must submit a statement in support of an exception.

There are national coverage determinations (NCDs) and local coverage determinations (LCDs). A request to issue an NCD must be made to CMS, but a request to issue an LCD must be made through the local Medicare Administrative Contractor. An individual can file a challenge with CMS to get a policy overruled even if he or she did not receive the service. Additionally, relief may be in the form of changing the policy, rather than awarding coverage.

A statement by a pharmacy, not by the plan, that the plan will not cover a requested drug is not a coverage determination. Enrollees who want to appeal must contact their plan to get a coverage determination. Drug plans must arrange with their network pharmacies to post generic notices telling enrollees to contact the plan if they disagree with information provided by the pharmacist.

Redetermination by Drug Plan
If a coverage determination is unfavorable, a beneficiary has 60 days to file a written request for a redetermination by the Part D drug plan. The plan may accept oral requests. The plan must act within seven days for a standard appeal. For an expedited appeal, the plan must act within 72 hours.

Reconsideration by Individual Review Entity (IRE)
The next level of appeal is reconsideration by the Individual Review Entity (IRE). For a standard appeal, the beneficiary has 60 days to file a written request, and the IRE must act within seven days. For an expedited appeal, the IRE must act within 72 hours.

Hearing before Administrative Law Judge (ALJ)
The next level of appeal is a fair hearing. As in other administrative matters, this hearing is held before an Administrative Law Judge (ALJ). It is a quasi-judicial proceeding in which limited discovery can be taken. The hearing before an ALJ is similar to a hearing in a civil court. Typically, the judge will make a written decision shortly after taking testimony and listening to arguments.

Medicare Appeals Council Review (MAC)
After the ALJ makes a determination, there is a review by the Medicare Appeals Council Review (MAC). This council can either uphold or reverse the determination made at the fair hearing.

Federal Court
The next level of appeal is with the federal court. Pleadings must be filed shortly after the receipt of the determination of the MAC. The court will then set forth a schedule for briefing and arguments.

Grievances
Each drug plan must have a separate grievance process to address issues that are not appeals. These grievances may be filed orally or in writing within 60 days. Plans must resolve grievances within 30 days, or within 24 hours if the grievance arose from a decision not to expedite a coverage determination or redetermination.

Appeals Issues
Notice
Representatives must receive Medicare Summary Notices.

Evidentiary Issues
Medicare Part D appeals involve burdensome evidentiary standards. Providers must submit evidence at reconsideration. Beneficiaries must submit evidence at the ALJ hearing.

Timeliness and Time Frames
Compliance with timeframes depends on who is issuing the decision. The overall process is quite lengthy. There are no time frames to issue ALJ decisions in Part D cases.

Conduct of ALJ Hearings
Individuals must request the record of a pre-hearing case review and may have to pay the costs of such.

Representing a Client
An appointment of representative form must be completed and signed by the beneficiary and the representative. This form authorizes the release of identifiable health information to the representative. It also explains the purpose and scope of the representation. This form is filed with the entity processing the party’s initial determination or appeal. The appointment form is valid for one year, but it remains valid if the appeal takes longer than one year. If an individual files multiple appeals during the year, he or she must file a copy of the original form with each appeal.

Legal Fees
Below the ALJ level, legal fees are not regulated. CMS must approve legal fees for work done at the ALJ and MAC levels; however, there is no standard fee schedule. Attorneys’ fees are not paid out of the award to the client or out of the Medicare trust fund.
The Medicare Appeals process requires great detail and organization, and the ability to navigate a maze of rules and regulations. And, as each drug plan also has a separate grievance process, individuals will benefit by getting legal counsel to skillfully ensure compliance with all the steps. Begley Law Group, PC can successfully complete these processes for you so you can focus on yourself or your loved one during this critical time. To learn more, go to www.begleylawgroup.com or call 800-533-7227.

Begley Law Group, P.C.
509 South Lenola Road, Building 7
Moorestown, NJ 08057

Thomas D. Begley, III, CELA is a New Jersey elder law attorney with The Begley Law Group. To contact a New Jersey estate planning, special needs planning, or elder law attorney, call 1.800.533.7227 or visit http://www.begleylawyer.com.