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Improving the Managed Care Appeals Process

During this meeting session, staff presented policy options for the appeals process in Medicaid managed care.

Medicaid managed care organizations (MCOs) manage and provide care to beneficiaries enrolled in their plans. This includes authorizing and paying for covered services, as well as denying or limiting services to ensure that only appropriate, medically necessary care is provided (42 CFR § 438.210). Beneficiaries have the right to appeal MCO coverage decisions. Federal rules require that states have monitoring systems in place to provide oversight of MCOs and their appeals systems.

This session described key challenges with the current requirements for the appeals process, and explored policy options to address these challenges. Staff also solicited Commissioner feedback on these policy options.