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 Medicaid Services for dual eligible demonstration projects. Creating … Continue reading
Category Archives: appeals
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 ombudsman who can provide individual assistance and … Continue reading
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 services and then waiting to see whether … Continue reading
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 appeal before an external review of the … Continue reading
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 timelines. The faster decision deadlines that Medicare imposes on … Continue reading
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 provides this protection to enrollees who are eligible for Medicaid. Dual eligibles are … Continue reading
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 eligibles to absorb. For more information, … Continue reading
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 … Continue reading