The Medicaid managed care grievance process: new protections for beneficiaries

The Centers for Medicare and Medicaid Services (CMS) recently proposed regulations to enhance protection of the rights of Medicaid managed care enrollees to appeal decisions made by their managed care plans. The regulations would require both internal and external beneficiary grievance processes that could have a significant effect on managed care organizations with multiple lines of business operating in several states. Managed care organizations may find it worthwhile to develop a standard grievance process that meets Medicaid and Medicare requirements and can be used by enrollees in commercial plans. In addition to saving money and reducing confusion, a well-structured internal grievance process for all product lines would be useful as part of a quality-improvement initiative. Data from grievances may provide information that can help healthcare providers update medical protocols.