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.

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.

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.

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