Denials in Medicaid Managed Care and the Appeals Process – Beneficiary Experience

Because Medicaid managed care plans play a large role in providing health care services and are governed by federal regulations, Mathematica convened focus groups to deepen MACPAC’s understanding of existing managed care oversight to inform efforts to better monitor beneficiary access to care and address potential inequities.

Mathematica conducted focus groups in eight states to understand the accessibility of the appeals process to beneficiaries, barriers to the appeals process, the type of health beneficiaries receive from Medicaid managed care plans, state Medicaid agencies, and other organizations in pursuing appeals, and changes to policies or procedures that could make the appeals process more accessible. As part of this work, Mathematica wrote a report on the major findings from the focus groups and identify remaining knowledge gaps.