Grievances and Appeals

Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned Enrollment”

On April 16, 2019, CMS released a final rule that implements provisions of the 2018 Bipartisan Budget Act (BBA) requiring greater D-SNP integration, including integrated plan-level appeal and grievance processes for certain “applicable integrated plans.” This fact sheet is intended to help states with applicable integrated plans understand the new integrated appeal and grievance processes, the types of D-SNPs that are required to use them, and steps that states can take to help ensure effective implementation of the new processes in 2021.

View Resource:

Contract Year 2021 Models for Applicable Integrated Plans: 'Letter about Your Right to Make a Fast Complaint' and 'Appeal Decision Letter'

This CMS memorandum describes the final Contract Year 2021 model notices for Dual Eligible Special Needs Plans that are applicable integrated plans, "Letter about Your Right to Make a Fast Complaint" and "Appeal Decision Letter", which are both available in English and Spanish language versions.

Integrated Care Updates - February 2020

February 2020 Update Content:

Integrated Care Updates - April 2020

April 2020 Update Contents:

CMS Updates Processes for D-SNPs Implementing CY 2021 Medicare-Medicaid Integration and Unified Appeals and Grievance Requirements in Response to COVID-19: Clarification on Direct Contracts with States

Centers for Medicare & Medicaid Services (CMS) issued a memo detailing important updates on CMS processes for review and approval of state Medicaid agency contracts (SMACs) for contract year 2021. These updates acknowledge the unique circumstances resulting from Dual Eligible Special Needs Plans’ (D-SNPs’) and states’ priority focus on the COVID-19 public health emergency.

Integrated Care Updates - January 2020

January 2020 Contents:

New ICRC Flow Charts Compare Existing and New Unified Appeals and Grievance Processes for Individuals Enrolled in Applicable Integrated D-SNPs
CMS Releases Additional Guidance on D-SNP Integration Requirements
CMS Releases the 2021 Medicare Advantage Advance Notice
MACPAC Considers Policy Options to Better Integrate Care for Dually Eligible Individuals
January 2020 Enrollment in Medicare-Medicaid Plans
January 2020 Enrollment in PACE Organizations
Key Upcoming Dates

Appeals and Grievances: Comparisons of Existing and New Integrated Processes for Individuals Enrolled in Applicable Integrated Plans

Beginning in 2021, Dual Eligible Special Needs Plans (D-SNPs) with exclusively aligned enrollment must begin using integrated appeals and grievance processes. The flowcharts in this resource are designed to help states, health plans, and other stakeholders understand the differences between existing Medicare and Medicaid appeal and grievance processes and the new integrated appeal and grievance processes established at 42 CFR Part 422 Subpart M for fully and highly integrated D-SNPs with exclusively aligned enrollment.

Integrated Denial Notice

Study Hall Call

November-13

This webinar provides background on the integrated denial notice and discusses the applicability of the integrated denial notice outside of the financial alignment demonstrations, using New York as an example.

Integrated Appeals & Grievances

Study Hall Call

April-13

Provides an overview of the Medicare appeals process and gives examples of the integrated Medicare/Medicaid appeals processes proposed in California, Massachusetts, Ohio, and New York.

Proposed Model for Integrating the Medicare and Medicaid Appeals Processes

This document describes a proposed strategy to integrate the Medicare and Medicaid appeals processes for D-SNPs.

View Resource:

View Resource

Search form

Pages