Enrollees in integrated models may disagree with decisions the integrated model 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. Enrollees must have the ability to appeal decisions made by the integrated model and to file complaints about problems encountered in dealing with the model.
Appeal rights encompass many issues including:
- Right to appeal eligibility for or enrollment in the model;
- Right to appeal an assignment to a provider or care team;
- Right to appeal a decision regarding provision of a particular service;
- Right to appeal elements or non-elements of a care plan;
- Right to request a second opinion or evaluation of eligibility for a service (to support an appeal);
- Right to appeal a denial of coverage of a service; and
- Right to file a grievance/complaint about the integrated model and/or its providers.
Given the high level of vulnerability in this population, the appeal system should include the best protections provided by the collective Medicare and Medicaid appeals processes. Elements should include: due process protections, clear notices in a language the enrollee can understand, coverage of care pending the appeal (referred to in Medicaid as “aid paid pending”), opportunities for expedited review, a path to a review by an independent decision-maker and the right to appeal to an administrative law judge and, if necessary, federal court.
For more information, see NSCLC’s issue brief, “Building an Integrated Appeals System for Dual Eligibles”