Crosswalk

Currently approved version	Renewal package version	Type of Change	Reason for Change	Burden Change
Plan Appeal: Ask {health plan name} for an appeal within 60 days of the date of this notice. We can give you more time if you have a good reason for missing the deadline. See section titled “How to ask for an appeal with {health plan name}” for information on how to ask for a plan level appeal.	Plan Appeal: Ask {health plan name} for an appeal within 65 calendar days of the date listed at the top of this notice. If you ask for an appeal after 65 days of the date of this notice, you must explain why your appeal is late. See “How to ask for an appeal with {health plan name}” on the next page.	Substantive	The timeframe to file an appeal with the plan was amended in CMS-4205-F to allow 65 days rather than 60 days. This change was made to account for the time it takes for an enrollee or other appropriate party to receive the notice.	No
	Under section "You have the right to appeal our decision", the following language was added: [If you need help getting a Medicaid service, asking for a Medicaid appeal, or would like to request information to support your Medicaid appeal, contact {health plan name} at {Insert toll free and TTY phone numbers} {Insert plan hours of operation}].	Substantive	This language was added to comport with the requirements at 422.562(a)(5) which requires D-SNPs to offer Medicaid assistance.	No
	Based on consumer testing and CMS Office of Communications review, several changes were made to improve clarity and readability for the person receiving this notice. These changes are non-substantive and are intended to ease use and utilize more plain language.	Non-substantive	Updated language and formatting to utilize more research- based ‘plain language’ and formatting consistent with current CMS guidelines. In response to consumer testing, we also made revisions to improve clarity for the reader.	No
We use "Part B drug" throughout the notice.	We have revised each instance where we say "Part B drug" to say "Medicare Part B drug"	Non-substantive	This was in response to a comment received during the 60-day comment period. We have revised the langauge from "Part B drug" to "Medicare Part B drug" to avoid confusion for members enrolled in a Dual Special Needs Plan (D-SNP).	No
In the section entitled "Important Inforamtion About Your Appeal Rights", the lanuage related to an extension was not in brackets and intended to be used in every denial notice.	We added brackets around this language and included instruction to only insert the language for requests for a medical service/item. [insert for requests for medical service/item: Our decision might take longer if you ask for an extension, or if we need more information about your case. We’ll tell you if we’re taking extra time and will explain why more time is needed.]	Substantive	This was in response to a comment received during the 60-day comment period. Part B drug requests cannot be extended; therefore, the language is not applicable for each denial notice. Making this language optional will avoid any confusion for enrollees.	No
Revised the title of the section "Why did we deny your request?"	This title has been revised to read "Why was coverage {Insert appropriate term: denied, partially approved, stopped, reduced, suspended}?". The plan will need to fill in the appropriate decision issued.	Non-substantive	This was in response to a comment received during the 60-day comment period. This change allows the plan to be more specific about the decision that was made rather than just saying the request was denied. This enhances the enrollee's understanding about the decision that was made about their coverage of the requested medical service/item or Medicare Part B drug.	No