A new report from the Government Accountability Office (GAO) examines the first year of data on Medicaid managed care appeals and grievances reported to the Centers for Medicare & Medicaid Services (CMS).
States are required to monitor managed care plans’ performance and, beginning in 2022, report appeals and grievance data to CMS. Because managed care pays insurers per enrollee, there can be financial incentives for plans to deny or limit services; this data collection aims to safeguard beneficiaries and protect access to care.
Data indicates that rates of appeals and grievances per 1,000 enrollees varied widely across states in 2022. However, CMS does not require states to report on the outcomes of beneficiary appeals or the number of denials, which are key data elements to identifying potential problems with access to services. GAO also found that CMS had made little progress on its plans to analyze the data and make it available to the public.
GAO recommends that CMS:
- Require states to report on the outcomes of Medicaid managed care appeals and number of denials.
- Implement its planned actions for analyzing the Medicaid managed care appeals and grievance data, using it for oversight, and making it publicly available.
Contact Director of Policy Rob Nelb, MPH, at rnelb@essentialhospitals.org or 202.585.0127 with questions.