Integrated Appeal and Grievance Processes for Integrated D-SNPs with “Exclusively Aligned Enrollment”

Individuals dually eligible for Medicare and Medicaid must navigate separate, and in some cases conflicting, appeal and grievance processes within Medicare and Medicaid. Integrated plans that cover both Medicare and Medicaid benefits are designed to help alleviate this challenge, but historically, even enrollees in integrated plans have had to navigate separate processes when filing appeals or grievances. To address this issue, the Centers for Medicare & Medicaid Services (CMS) will begin requiring integrated appeal and grievance processes for dually eligible individuals who are enrolled in certain Dual Eligible Special Needs Plans (D-SNPs) in 2021. On April 16, 2019, CMS released a final rule1 that implements provisions of the 2018 Bipartisan Budget Act (BBA) requiring greater D-SNP integration, including integrated plan-level appeal and grievance processes for certain “applicable integrated plans.” This fact sheet is intended to help states with applicable integrated plans understand these new integrated appeal and grievance processes, the types of D-SNPs that are required to use them, and steps that states can take to help ensure effective implementation of the new processes in 2021.