Medicaid Appeals Lag Behind Medicare Advantage: New data Reveals Gaps in Access to Autonomous Reviews
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Washington, D.C. – July 2, 2024 – A new analysis of state Medicaid managed care organizations (MCOs) reveals significant disparities in access to independent appeals processes compared to Medicare Advantage plans, perhaps leaving beneficiaries wiht fewer avenues to challenge denied healthcare services. While over a third of states now offer external medical reviews for Medicaid MCO denials, the rate of successful appeals remains dramatically lower than in Medicare Advantage, where independent review is automatic.
This finding underscores ongoing challenges in ensuring equitable access to care and robust appeals rights for the over 80 million Americans enrolled in Medicaid managed care.
Understanding the Medicaid Managed Care Appeals process
Medicaid increasingly relies on managed care organizations to deliver healthcare services to beneficiaries. When an MCO denies a requested service, enrollees have the right to appeal. The process typically begins with an internal appeal to the MCO itself.However, navigating this system can be complex, and enrollees may feel hesitant to seek assistance from the very entity that initially denied their care.Federal regulations require MCOs to assist enrollees with the appeals process upon request, but a recent report from the Office of Inspector General (OIG) highlighted that even standard appeal templates sometimes omit crucial facts, such as the enrollee’s right to a state fair hearing.
External support, like ombudsperson offices and legal aid societies, can be vital in helping enrollees navigate these appeals. Tho, a recent survey indicates inconsistent state funding for these external entities, making it unclear how many states actively support such assistance programs.
The Role of External Medical Review
States have the option, but are not required, to offer an external medical review (EMR) following an MCO’s upheld denial. An EMR provides a clinical assessment of the denial by an independent, third-party reviewer with no affiliation to the state or the MCO. If offered, this review must be free to the enrollee, cannot interrupt ongoing healthcare coverage, and cannot discourage pursuit of a state fair hearing – a more formal administrative review involving an administrative law judge.
The contrast with Medicare Advantage is stark. In Medicare Advantage, cases are automatically sent for independent review after an MCO denial is upheld. This automatic process is believed to contribute to a considerably higher appeal overturn rate – 82% in Medicare Advantage versus just 36% in Medicaid mcos,according to OIG data.
Current State of External Review Access
As of July 1, 2024, data from a 2024 KFF/HMA state survey shows that at least 15 out of 39 responding Medicaid MCO states (roughly 38%) provide access to an independent external medical review process. This represents a modest improvement compared to OIG findings from 2019.
[Image of Datawrapper chart showing “At Least One-Third of MCO States Provided Enrollees Access to an Independent External Medical Review process to Review Denials upheld by MCOs”]
Key Takeaways & Future Considerations
Disparities in Appeals Access: Medicaid enrollees face significantly fewer automatic safeguards in the appeals process compared to Medicare advantage beneficiaries.
Limited External Review Availability: While increasing,access to independent external medical reviews remains limited across Medicaid MCO states.
Need for Consistent Funding: Clearer data is needed on state funding for external entities that assist enrollees with appeals.
Template Deficiencies: Standard appeal templates sometimes lack critical information, hindering enrollees’ understanding of their rights.
These findings highlight the need for increased state and federal attention to strengthening Medicaid managed care appeals processes, ensuring equitable access to care, and empowering beneficiaries to effectively challenge denials. Further research is needed to understand the barriers to implementing more robust external review systems and to evaluate the impact of increased access on appeal outcomes.
