Under Medicare law, Medicare Advantage plans and stand-alone Part D plans (“Plans”) must follow certain rules when enrollees disagree with Plan health care coverage determinations. Under the law, there are two distinct methods for raising issues with Plans when enrollees are dissatisfied with their Medicare determinations or actions – Appeals and Grievances. Knowing the difference between Appeals and Grievances is essential to safeguarding a Plan enrollee’s Medicare rights.
Appeals are the process to contest adverse Medicare coverage determinations made by a Plan. Appeals may include a delay or a denial to approve or provide health care service or drug coverage, or to determine costs the enrollee must pay for a service or drug.
Appeals address an individual’s specific denial of Medicare coverage. For example, if a Plan decides to terminate Medicare coverage of a skilled nursing facility stay, an enrollee can initiate the appeals process to challenge that determination and argue that Medicare coverage is appropriate under the law. In this process, an enrollee typically has multiple opportunities to appeal in order to determine if the disputed health care coverage should be provided under the applicable legal Medicare standards. An appeal is essential if an enrollee wants to challenge and reverse a specific Medicare coverage denial.
For more information on how to appeal a Plan’s coverage denial, please visit the following Center for Medicare Advocacy link: https://medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals/
Grievances are formal complaints about general Plan processes, rather than a specific claim for coverage or costs, that can be filed with a Plan. Grievances will not reverse a specific Medicare coverage denial.
A grievance is an expression of dissatisfaction with any aspect of the operations, activities, or behavior of a Plan in the provision of health care or prescription drug services or benefits, regardless of whether remedial action is requested. Decisions made under the grievance process are not subject to appeal.
Although Plans are required by law to respond to an enrollee’s grievance, remedial action to correct the source of dissatisfaction is not necessarily required. The grievance process is handled by the Plan – no response from an entity outside of the Plan is required upon the filing of a grievance. However, Plans are required both to have meaningful procedures for timely resolution of grievances and to report grievance data to the Centers for Medicare & Medicaid Services (CMS).
For more information on how to file a grievance with a Plan, please carefully review the grievance procedures explained in your plan documents and visit the following Center for Medicare Advocacy link: https://medicareadvocacy.org/wp-content/uploads/2022/11/MA-Plan-Grievance-Form.pdf