Medicaid managed care organizations (MCOs) manage and provide care to beneficiaries enrolled in their plan. While this includes authorizing and paying for covered services, MCOs may deny or limit services to ensure appropriate, medically necessary care is provided (42 CFR § 438.210). Beneficiaries have the right to appeal decisions by the MCO. Federal rules require that states have monitoring systems in place to provide oversight of MCOs and their appeals systems.
This session introduced a new project examining denials and appeals in Medicaid managed care. Analysts provided background and an overview of federal policy related to managed care plan processes and the oversight of these activities and decisions. Analysts also detailed the results of a state scan on public reporting of data on denials and appeals, and state reporting requirements for MCOs. Lastly, analysts reviewed next steps in this work.