Medicare Rights Highlights the Need for States to Integrate Medicare and Medicaid Appeals Processes

As part of an ongoing series examining Medicare and Medicaid integration, Health Affairs Forefront recently published an article from the Medicare Rights Center titled “Integrated Appeals Are Essential, But Challenges Remain.” The article highlights the need for states to integrate Medicare and Medicaid appeals processes to best ensure dually eligible individuals are bolstered, not burdened, by their eligibility for both programs.

As research and experience consistently reveal, Medicare’s appeals system alone can be a significant barrier to care. It is confusing, daunting, and time-consuming, and as a result, rarely used. A recent report found that only 1% of Medicare Advantage denials were appealed. Of those that were appealed, 75% were overturned at the first level. This suggests many enrollees abandon needed services or pay for them out-of-pocket, possibly worsening their health and financial security. Even those who successfully appeal are not left unscathed; they experience care delays that may lead to negative health outcomes. Layering in distinct, complicated Medicaid appeal rules usually only compounds these problems.

On our national helpline, we frequently hear from people who are struggling with these separate systems. As the article notes, such difficulties are wide-ranging and begin well before an appeal is filed:

“Dually eligible individuals receiving a denial for care may not understand whether to file an appeal with Medicare or Medicaid, often due to a lack of clear information. Significant differences in appeal procedures and timelines between Medicare and Medicaid add further complexity that beneficiaries are left to navigate. And Medicaid payers that do not understand Medicare’s complex rules and their interaction with Medicaid benefits can also be a significant source of problems.”

Several states have attempted to address this by streamlining Medicare and Medicaid appeals. Those efforts have typically focused on the first level of appeal. In 2015, as part of the Fully Integrated Duals Advantage (FIDA) demonstration, New York was the first state to align all four appeal levels. Though the program ended in 2019, many policymakers, participants, providers, and plans continue to support the single integrated appeals process.

Building on this momentum, in 2020, New York launched a new three-year demonstration, preserving FIDA’s integrated grievances and appeals process within the state’s 12 Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs). As of June 2022, nearly 34,000 people were enrolled in these plans, compared to approximately 2,000 FIDA enrollees. While we welcome this important progress, obstacles to complete alignment persist—as does our own and collective work to overcome them.

Over the years, Medicare Rights has had the unprecedented opportunity to help New York move closer to realizing the promise of full Medicare-Medicaid integration. For more about the lessons we have learned so far and our hopes for the future, read our Health Affairs Forefront article.