Navigating Medicaid Managed care Appeals: Your Rights and Available Resources
Medicaid Managed Care Organizations (MCOs) offer a vital pathway to healthcare for millions, but denials of services can create notable hurdles for enrollees. Understanding your appeal rights and the resources available to you is crucial. This article breaks down the Medicaid appeals process, highlighting recent findings and outlining how you can advocate for the care you need.
Understanding the Appeal Process
When an MCO denies a service request, you have the right to appeal. The process typically begins with an internal review by the MCO itself. However, relying solely on the MCO for information can be problematic.
Recent reports from the Office of the Inspector General (OIG) reveal that even standard appeal language provided by states sometimes omits critical information. For example, one state’s template didn’t inform enrollees about their right to a state fair hearing after an MCO appeal denial.
Moreover,you may feel hesitant to seek help from the very entity that denied your care. This is where external support becomes invaluable.
External Assistance: Your Advocate in the System
Fortunately, several resources can help you navigate the appeals process:
Ombudsperson Offices: These autonomous offices can investigate your concerns and advocate on your behalf.
Legal Aid Societies: Legal professionals can provide guidance and portrayal, notably for complex cases.
Other Advocacy Groups: Numerous organizations specialize in healthcare access and can offer support.
However, a recent survey revealed inconsistent funding for these external entities across states. While states can provide Medicaid funding to support these organizations, it’s unclear how many actually do.
Independent External Medical Review: A Critical Option
If the MCO upholds its initial denial, you may have the right to an Independent External Medical Review (IEMR). This is a clinical review of the MCO’s decision by a third party - an unbiased medical professional not affiliated with the state or the MCO.
Here’s what you need to know about IEMRs:
It’s optional for states: States aren’t required to offer IEMRs,but those that do must provide it at no cost to you.
Benefits must continue: Your healthcare coverage cannot be interrupted during the review process.
No deterrent to fair hearings: An IEMR cannot prevent you from pursuing a state fair hearing, which involves an administrative law judge.
A Stark Contrast: Medicare Advantage vs. Medicaid
The availability of IEMRs differs substantially between Medicare Advantage and Medicaid. In Medicare Advantage, cases automatically proceed to an independent review if the initial denial is upheld. This automatic review may explain why Medicare Advantage boasts an 82% appeal overturn rate – dramatically higher than Medicaid MCOs’ 36%.
Current Access to Independent External Medical Review
As of July 1, 2024, at least one-third of responding Medicaid MCO states (15 of 39) provide access to IEMRs. This represents a slight improvement compared to 2019 findings, but significant gaps remain.
What You Should Do
If your Medicaid MCO denies a service, remember:
- Understand your appeal rights. Don’t hesitate to ask the MCO for a clear description of the process.
- Seek external assistance. Contact your state’s ombudsperson office, a legal aid society, or a healthcare advocacy group.
- Determine if an IEMR is available. If so, pursue this option for an unbiased review of your case.
- Don’t give up. You have the right to advocate for the healthcare you need.
Resources:
OIG Report: Medicaid Managed care Appeals and Grievances
[MACPAC: Chapter 2 – Denials and appeals in Medicaid
