AHIP Medicare - Module 2 - Enrollee Protections Appeals and Grievances

Enrollees of a Medicare Advantage plan, Medicare Cost plan, PACE plan, or MMP have a right to:
- file complaints (sometimes called grievances), including complaints about the quality of their care.

• get a decision about health care payment or services, or prescription drug coverage.

• get a review (appeal) of certain decisions about health care payment, coverage of services, or prescription drug coverage.

The grievance process is used for complaints about the operations of a plan or its network providers.

– Enrollees or their representatives may file a grievance if they experience problems with their health care services such as timeliness, appropriateness, access to, and/or setting of a provided health service, procedure, or item.

– Grievance issues also may include complaints that a covered health service, procedure, or item furnished during a course of treatment did not meet accepted standards for the delivery of health care.

– An enrollee or their representative may make the complaint orally, in writing, or via a CMS website at Https://www.medicare.gov/MedicareComplaintForm/home.aspx.

– Plans must also provide a link to the Medicare.gov website where the enrollee can enter a complaint.

Coverage decisions are determinations made by a Medicare health plan concerning whether medical care or prescription drugs are covered, how they are covered, and the beneficiary’s share of the cost.

– An enrollee has a right to ask for prior authorization even when it is not required to find out if a service will be covered by the plan.

Examples of times when an enrollee may need a coverage decision include:

• To get prior authorization for a provider to furnish a service.

• To obtain payment for certain items or services, such as the type or level of services the enrollee thinks should be furnished.

To obtain payment for services when the enrollee is temporarily out of the area..

–To continue a service that the enrollee believes is medically necessary.

– To obtain payment for a prescription drug.

– To ask for an exception from a plan’s formulary requirements (including step therapy requirements) or tiering structure for prescription drugs.

The appeals process is used to ask for a review of the plan’s coverage or payment decisions.
– If an enrollee is not satisfied with the coverage decision, they, or in some cases their physician, can appeal the decision.
- Physicians can appeal prior authorization denials on behalf of their patients.

– An appeal is a formal way to ask the plan to review or change a coverage decision.

An appeal can also be filed if:

1. an enrollee believes a Medicare health plan did not pay for or authorize a service that should be covered. Where the plan did not pay, the enrollee must be financially liable in order to appeal.

2. an enrollee believes an authorized service such as a hospitalization or home health care is ending too soon.

3. an enrollee believes a plan has not authorized or paid for a Part D prescription drug that should be covered.

Yes. Medicare health plans must provide enrollees with a written description of the appeal process.

Medicare health plans offering a Part D benefit must:
1. provide access via a secure website or secure e-mail address on the website for enrollee to quickly request a coverage determination or appeal a decision about coverage of a drug.

2. require network pharmacies to provide enrollees with a printed notice with the plan’s toll-free number and website for requesting a coverage determination concerning a drug.