Denials and Appeals in Medicaid Managed Care

Chapter 2 looks at the monitoring and oversight of denials and appeals in Medicaid managed care and the beneficiary experience with the appeals process. Beneficiaries appeal few denials, and program operators do not collect comprehensive information about denials in Medicaid managed care. Federal rules do not require states to collect and monitor data needed to assess access to care, monitor the clinical appropriateness of denials, or require that states publicly report information on plan denials and appeals outcomes.

This chapter lays out the current federal requirements for the appeals process as well as for monitoring, oversight, and transparency; elaborates on state flexibilities within the current federal framework; and describes key challenges with the current structure. The Commission makes seven recommendations to improve the appeals process and enhance monitoring, oversight, and transparency efforts.