During this session, staff presented new findings from MACPAC’s ongoing examination of managed care denials and appeals. Staff shared findings from a detailed examination of selected states and interviews with key stakeholders across these states.
Medicaid managed care organizations (MCOs) manage and provide care to beneficiaries enrolled in their plan. This includes authorizing and paying for covered services, as well as denying or limiting services to ensure that only appropriate, medically necessary care is provided (42 CFR § 438.210). Beneficiaries have the right to appeal MCO coverage decisions. Federal rules require that states have monitoring systems in place to provide oversight of MCOs and their appeals systems.
This session discussed detailed interview findings that address whether denial and appeal processes ensure beneficiary access to covered and medically necessary care and how state and federal officials monitor the denial and appeals processes of Medicaid MCOs. Staff also solicited Commissioner feedback on areas where they may be interested in pursuing policy options at a future meeting.