A new report from the Office of Inspector General (OIG) reviews the appeals and grievance systems for Medicaid managed care programs. With over 70% of Medicaid enrollees receiving services through managed care, the Centers for Medicare and Medicaid Services (CMS) started requiring states to monitor appeals and grievances data for plan performance. The report found wide variation in appeal and grievance rates across and within states.

OIG found significant gaps in the data collection which, if unaddressed, could limit CMS’ use for oversight moving forward. OIG made the following two recommendations to CMS:

• The Administrator of CMS should require states to report on the outcomes of Medicaid managed care appeals (e.g., the extent to which they were decided in favor of enrollees) and number of denials.
• The Administrator of CMS should implement its planned actions for analyzing the Medicaid managed care appeals and grievances data, using it for oversight, and making it publicly available.