Appeals and grievance procedures must be comprehensive and accessible
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...
View ArticleMedicare’s amount in controversy should not apply
This barrier to access to a hearing or to court review should not apply to dual eligibles pursuing appeals in integrated models. Costs below the Medicare thresholds are well above the ability of dual...
View ArticleBenefits should continue pending an appeal; for LTTS aid paid pending should...
Integrated models should provide continued benefits while pursuing an appeal regardless of whether those benefits would be classified as Medicare or Medicaid benefits. The PACE program currently...
View ArticleProvide fair timelines for filing appeals and fast decision deadlines
Dual eligibles need speedy resolution of appeals. They cannot afford to pay for denied services and their medical needs are complex. Integrated models and government agencies should be held to strict...
View ArticleNo more than five levels of appeal are needed; Beneficiaries should have...
An integrated appeal process should never exceed five levels of appeal and beneficiaries should not be required to pursue every level of appeal. There should be no more than one internal, plan level...
View ArticleFollow Medicaid’s rules regarding notice timing and content
The Medicaid process of providing a notice prior to the provision or termination of a service is of critical importance for this population. Dual eligibles are unable to afford the risk of receiving...
View ArticleA Dedicated, Funded Ombudsman Program Is Essential
One risk of the dual eligible integration models is that new incentives will arise for plans and providers to deny needed care. To address this risk, enrollees should have access to an independent...
View ArticleAnalysis Compares Appeals Systems in Dual Eligible Demonstration Projects
NSCLC has published an advocacy tool that compares the design of the appeals systems for the six states that currently have a Memorandum of Understanding (MOU) with the Centers for Medicare and...
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