The Commission continued its discussion on denials and appeals in Medicaid managed care. MACPAC staff presented a draft chapter for the March 2024 report to Congress with seven recommendations aimed at improving the beneficiary experience with the appeals process and monitoring, oversight, and transparency of denials and appeals.
The chapter lays out the current federal requirements for the appeals process as well as for monitoring, oversight, and transparency, and elaborates upon state flexibilities within the current federal framework. Drawing on Commission discussions and findings from a state scan, state and stakeholder interviews, and beneficiary focus groups, the chapter describes key challenges with the current structure of both the appeals process and monitoring, oversight, and transparency of denials and appeals. The chapter includes the rationale and implications for Commission recommendations. The chapter concludes with additional considerations for states and next steps.
The Commission voted in favor of the seven recommendations to improve the appeals process and enhance monitoring, oversight, and transparency efforts: (1) require states to establish an independent, external medical review process; (2) release federal guidance on improving denial notices and appeals; (3) require managed care organizations to allow for beneficiary choice of electronic denial notices; (4) extend the timeline for continuation of benefits and issue guidance on this beneficiary protection; (5) require the collection of data on denials, continuation of benefits, and appeal outcomes; (6) require routine clinical audits of denials; and (7) publicly post all managed care program annual reports, and require states to incorporate denials and appeals data onto quality rating system websites.