Administrative Law Judge Hearings
for Medicare Advantage Plans
and Prescription Drug Plans
Administrative Law Judge (ALJ) Hearings
An ALJ hearing is a hearing conducted by an Administrative Law Judge. You can
appeal to the ALJ after you’ve gotten a denial for either health care services or
drugs from the Independent Review Entity (IRE). The IRE is a company called
MAXIMUS Federal Services. You don’t need to go to court for an ALJ hearing. These
hearings are usually held over the phone.
Drug Plan Appeals
Health Plan Appeals
Your pharmacist tells you that your
drug isn’t covered by plan
You receive a written denial from
your plan for a medical service
You and your doctor request an
exception from the plan and your
request is denied
You write a letter to your plan asking
it to reconsider and your request is
denied
You write a letter to your plan
asking it to reconsider and it still
won’t cover your drug
You appeal the decision to the
Independent Review Entity. The
plan’s decision isn’t overturned
You appeal the decision to the
Independent Review Entity. The
plan’s decision isn’t overturned
You request an ALJ Hearing
You request an ALJ Hearing
Requesting an ALJ Hearing
When you receive an unfavorable decision from the Independent Review Entity, you
must request an ALJ hearing within 60 days from the date on the denial. To request an
ALJ hearing, you should write a letter to the address listed on the MAXIMUS decision.
The letter should include:
 A request for the appeal of the MAXIMUS denial
 Your name
 Your Medicare number
 The name of your plan
 Your plan ID number
Mail the letter return receipt requested or certified so that you’ll be able to track it. Also,
make sure you keep a copy of the letter.
© 2017 Medicare Rights Center
Helpline: 800-333-4114
www.medicareinteractive.org
Preparing for the Hearing
It may take a month or two before the Judge’s office is able to schedule your hearing.
When it’s scheduled, you will get a notice of the hearing with a form you must return
within five days. This form lets the Judge’s office know you’ve received the information
about the hearing. The form also asks you to provide a telephone number where you
can be reached. This is the number the judge will call you on for your hearing, so it’s
best to use a stable connection.
Once you receive the notice of the hearing, you’ll have 10 days to submit any
additional evidence or a written argument to the Judge. If you think you’re going to have
trouble meeting this deadline, you should contact the court clerk to request more time.
When you receive the notice, you should also call the court clerk and ask for a full copy
of the court’s record. The record contains all the information that the Judge will look at
to make a decision. You may already have some of the documents contained in the
record, but it’s still best to ask for a complete copy of the record from the court clerk.
The clerk may ask you to put your request for a copy of the record in writing.
When you receive your copy of the court record, you should look through it and make
sure nothing is missing. If you see that information or documents aren’t there, you
should mail or fax them to the Judge’s office.
The Hearing
On the day of the hearing, the Judge or the court clerk will call you. You should be by
your phone at least 10 minutes before the scheduled time in case the Judge’s office
calls you early.
When the Judge comes on the phone, the Judge will introduce him or herself and then
summarize the issue. The Judge may then ask you some questions such as:
 Do you have a representative?
 Will you provide testimony?
 Do you understand that you’ll be under oath?
The Judge will then explain that the hearing will be recorded. The Judge will ask you to
spell your name for the record. If you’re testifying, you will be asked to take an oath to
tell the truth.
If you’re appealing a decision from your Part D plan or your Medicare Advantage Plan,
the plan may have a plan representative or a lawyer participate in the hearing. If they
do, the plan will be able to present their argument and you or your representative will
have a chance to respond to the plan’s argument. The plan will also have a chance to
respond to your argument.
If you’re giving testimony, your testimony is your chance to tell the Judge your story and
what steps you took to access treatment or drugs. Tell the Judge how important these
services or prescriptions are to you.
Your argument is different from your testimony. Your argument should tell the Judge
why the service or treatment is covered by Medicare. Your argument should be
supported by your testimony and evidence from the law, regulations or plan handbook.
© 2017 Medicare Rights Center
Helpline: 800-333-4114
www.medicareinteractive.org
The Decision
The Judge isn’t allowed to announce a decision over the phone. It can take two to three
weeks for the Judge to write a decision. The decision will be mailed to you.
Helpful Tips for ALJ Hearings
1. If you’re having trouble meeting a deadline, call the court clerk and ask for an
extension.
2. If you think you need help preparing for the hearing or representing yourself, you can
appoint a representative to represent you during the hearing. The representative can
be a friend, family member, doctor or lawyer.
3. Be prepared for the hearing, and make sure you can easily access the court record
and the documents that the Judge references.
4. Write out an outline of your testimony and arguments.
5. Have a pen and paper handy to write down any questions you may have while the
Judge or plan representative is speaking.
6. Be respectful. Always refer to the Judge as your “Your Honor” or “Judge.”
7. Don’t interrupt the Judge or the plan representative even if you think you’re being
misunderstood.
8. Remember that this hearing is about your case, and you shouldn’t be talking about
other issues such as health reform.
9. The Judge must make a decision based on the law and not necessarily what you
think is fair.
Case Example
What if plan XYZ denied payment for a doctor’s visit? During the hearing, plan XYZ’s
representative testifies that you went to see Dr. ABC on March 27, 2017, and Dr. ABC
isn’t in the plan’s network.
During your testimony, you would tell the Judge that you’re a member of XYZ plan
and that you’re from New York. On March 27, 2017, you were in California visiting your
sister. You fell while with your sister and were in a lot of pain. You were taken to the
hospital in California. You saw Dr. ABC at the hospital, and he treated you for a broken
bone.
During your argument, you would tell the Judge that under Medicare law, a plan is
required to cover care that is given to you by an out-of-network doctor if it’s an
emergency or urgent care situation. You know that Dr. ABC isn’t in the plan’s network,
but you needed that treatment and it was urgent care.
© 2017 Medicare Rights Center
Helpline: 800-333-4114
www.medicareinteractive.org