Appeals and Grievances

Individuals in MCOs may disagree with decisions the MCO and its providers make about what services are needed and whether coverage for those services will be provided. They may also have concerns about treatment by providers or members of their care team. Individuals must have the ability to appeal decisions made by the MCO and to file complaints about problems encountered in dealing with the MCO and its network.

  • Existing Medicaid due process rights – including the right to notice and to appeal a MCO decision – must apply to decisions by a MCO to deny, reduce or terminate LTSS.  If the MCO is also covering Medicare benefits, the rights associated with that program must also be included and efforts must be made by CMS, the state and the MCO to create an integrated appeals and grievance process.
  • Aid paid pending must be provided to individuals who appeal, within required timeframes, a reduction or termination of LTSS services.  MCOs must be prohibited from limiting the period of aid paid pending to a current authorization period.  Aid paid pending must continue until the resolution of an appeal.
  • Decision-makers in the appeals process must be trained to evaluate the necessity of LTSS, taking into account the non-medical goals and benefits of these services.
  • Individuals enrolled in the MCO must have the right to file grievances about the service and treatment provided by the MCO, its contractors and its providers.
  • The state must collect, and share publicly, data on the rate of denials (including partial denials) of requested services, the number of appeals and grievances filed and the number of appeals that result in the reversal of a MCO decision.
  • The state must establish an independent ombudsman to assist individuals through the appeals and grievance process.  (See discussion of Independent Ombudsman).
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