Integrated Appeals Are Essential, But Challenges Remain

Editor’s Note

This article is the latest in the Health Affairs Forefront major series, Medicare and Medicaid Integration. The series features analysis, proposals, and commentary that will inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.

The series is produced with the support of Arnold Ventures. Included articles are reviewed and edited by Health Affairs Forefront staff; the opinions expressed are those of the authors.

Submissions are accepted on a rolling basis.

While enrollment in both Medicare and Medicaid provides additional benefits and cost protections, poor integration between the programs can impede access for dually eligible individuals. On the Medicare Rights Center’s national helpline, we frequently hear from enrollees who are facing challenges navigating two convoluted appeals processes: one for Medicare and one for Medicaid.

Medicare’s appeals system alone can be a significant barrier to accessing care. A recent report from the Department of Health and Human Services Office of Inspector General (OIG) found that Medicare beneficiaries enrolled in Medicare Advantage or Part D experience a significant number of inappropriate pre-service and post-service denials, which can delay or prevent access to medically necessary care. Previous OIG analysis has shown that in 75 percent of cases, Medicare Advantage plans overturn their own denials when the beneficiary appeals. However, only 1 percent of beneficiaries appeal, likely due to the confusing and overwhelming process. As in previous years, the 2020–21 edition of our annual Helpline Trends report revealed that especially in times of significant stress and medical need, appeals are time-consuming and cause troubling delays.

When Medicaid appeals processes are factored in, these problems can be exacerbated. 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.

Case: A Medicare Rights Center client with a Medicare Advantage plan and a Medicaid managed care plan was denied coverage of a power wheelchair by the managed care plan because Medicaid is the payer of last resort and Medicare Part B covers power wheelchairs. However, the client was ineligible for Medicare coverage because they did not meet the Medicare coverage criteria for power wheelchairs.

In the case above, a beneficiary was incorrectly denied coverage by Medicaid due to the Medicaid managed care plan’s misunderstanding of Medicare’s coverage rules. Although plan decisions can be reversed via the appeals process, even a successful appeal comes at a cost to the beneficiary, including care delays that may result in negative health outcomes. Fundamentally, a well-functioning and truly integrated insurance product should not be placing additional strain on those it intends to serve.

State Attempts To Integrate Medicare And Medicaid Appeals

To address some of these issues, a handful of states have attempted to integrate Medicare and Medicaid appeals. In 2015, the Center for Health Care Strategies examined these efforts in Minnesota, California, and New York. In both Minnesota and California, integrated appeals were available at the first (plan) level—the request for reconsideration of a service denial with the plan. These states used several strategies to streamline the appeals process, such as using integrated notices for coverage determinations, approvals, and denials; aligning Medicare and Medicaid appeal filing time frames; maintaining preexisting beneficiary protections; and building plan staff expertise around beneficiary rights. These strategies successfully reduced the complexity of navigating multiple appeals processes for beneficiaries.

New York was the first state in the Financial Alignment Initiative demonstrations to integrate appeals beyond the first level. The 2015 Fully Integrated Duals Advantage (FIDA) demonstration fully aligned all levels of Medicare and Medicaid appeals for beneficiaries, applying provisions from each program in ways that were most helpful to beneficiaries. For example, unfavorable and partially unfavorable decisions were auto-forwarded to the next level of appeal. Automating this process ensured that beneficiaries would not miss appeal deadlines. “Aid continuing” protections enabled beneficiaries to continue receiving coverage for the denied service while the appeal was pending. (One way the FIDA appeals process could have been improved was by including the Part D appeals process in integration efforts. Its complexities can cause beneficiaries to miss the formal appeals process entirely and go without a drug.) Although the FIDA demonstration ended in 2019, many participants, providers, health plans, and other stakeholders continue to support the single integrated appeals process.

Since FIDA began, Congress passed the Bipartisan Budget Act (BBA) of 2018, which requires certain kinds of Dual-Eligible Special Needs Plans (D-SNPs) to integrate their grievance and appeals processes at the plan level. Many of the requirements echo strategies implemented by Minnesota and California. The Integrated Care Resource Center has also released materials to help states ensure that plan-level integrated appeals are effectively implemented.

Plan-level integration is an excellent start toward alleviating the problems that dually eligible individuals face when appealing, but it is only the first step. The BBA requirements do not apply to all D-SNPs, and even when integration functions well at the plan level, beneficiaries and their providers may still encounter difficulties when navigating beyond that level.

The Integrated Appeals And Grievances Demonstration In New York

Building on FIDA’s successes, the New York State Department of Health and the Centers for Medicare and Medicaid Services (CMS) designed the New York Integrated Appeals and Grievances (NY Integrated A&G) demonstration, which took effect in 2020 and will continue through 2023. The new demonstration goes beyond the requirements of the BBA, preserving FIDA’s integrated grievances and appeals process within New York’s 12 Fully Integrated Dual-Eligible Special Needs Plans (FIDE SNPs). Notably, the Part D appeals process remains unintegrated. In June 2022, approximately 34,000 New Yorkers were enrolled in these plans, although enrollment has continued to grow (compared to approximately 2,000 FIDA enrollees).

Dually eligible individuals enrolled in NY Integrated A&G-participating plans have four levels of appeal:

• Level 1—Plan Appeal
• Level 2—Integrated Administrative Hearings Office (IAHO)
• Level 3—Medicare Appeals Council
• Level 4—Federal District Court

Unfavorable or partially unfavorable appeals are auto-forwarded to the IAHO, which administers the state fair hearing. Beneficiaries denied at the IAHO may choose to continue appealing. Aid continuing is available at all levels to allow beneficiaries to continue receiving coverage for the service or item being denied while the appeal is pending. The NY Integrated A&G also implemented integrated notices and several other strategies used to streamline appeals in FIDA.

Despite this important progress, a few problems still stand in the way of New York providing an effective appeals experience. In March 2022, Research Triangle Institute International and the University of Southern Maine published a report on NY Integrated A&G after interviewing various stakeholders, including the state, plans, and advocates. These stakeholders explained that since the start of the program in 2020, IAHO fair hearing scheduling delays have been a persistent issue. Wait times between the initiation of a plan appeal and the fair hearing may stretch to more than six months. Most of these fair hearings are for personal care, so delays also result in plan assessments becoming outdated by the time the hearing is held, creating administrative burdens.

The report also found that plan members and their representatives struggle to obtain information from IAHO about their pending appeal and the schedule of their fair hearing. Initially, IAHO was unable to respond to telephone and email contact from plan members in a timely manner, but this has improved.

These problems may be the temporary result of New York adjusting to a total FIDE SNP enrollment much larger than FIDA while continuing to grapple with the COVID-19 pandemic. Addressing inadequate staffing may solve the lack of response from IAHO, as the state has said that staffing issues and turnover during the public health emergency are major sources of delays. At the start of the pandemic, there was already a significant backlog of cases in addition to the scheduling problems, and increased enrollment during the pandemic has likely worsened these issues. CMS previously addressed its own appeals backlog via increased adjudication capacity, encouraging resolution of cases earlier in the process, and seeking additional funding.

Medicare Rights, along with other New York advocates, has been involved since the initial creation and implementation of the integrated appeals process used in the FIDA program. Over the years, we have communicated issues and concerns from beneficiaries to the New York Department of Health, reviewed publicly posted integrated appeals decisions to assess outcomes and compliance with timelines, and supported beneficiaries and their representatives with the appeals process. To improve the NY Integrated A&G model, Medicare Rights and other stakeholders have urged increased staffing, improved oversight of Medicaid service denials, and a requirement for plans to authorize temporary coverage of services at the level requested by the member if the hearing cannot be scheduled and decided within the required time frame. Other suggestions include requiring that plans submit updated assessments and other relevant evidence two weeks before the hearing and to notify members when their appeal has been auto-forwarded and what to expect from IAHO.

Hope For Integration

To realize the promise of Medicare-Medicaid integration, the programs’ appeals processes must be improved and expanded. This means improving plan notices and education and streamlining processes but also including all products and services—including prescription drugs and long-term care—under the integrated appeals umbrella.

These principles must also apply beyond appeals. Programs and products must cover long-term care services, mental health services, and substance use disorder care as part of a fully integrated experience. These benefits are frequently carved out, causing confusion and hardship for beneficiaries (and their providers) as they attempt to piece together the appropriate care for their lives and circumstances. CMS should also assess why beneficiaries continue to enroll in unaligned and unintegrated Medicare and Medicaid plans and invest in protections, such as ombudsman programs, for all dually eligible beneficiaries.

We applaud the states that are striving to integrate care and appeals for people who are dually eligible for Medicare and Medicaid and hope our experience in New York can inform these efforts. Together, we can ensure that dually eligible individuals are bolstered, not burdened, by their eligibility for both programs.