Grievances and Appeals

CMS requires D-SNPs that qualify as AIPs—meaning they operate with exclusively aligned enrollment and cover certain Medicaid benefits through the D-SNP or the D-SNP’s affiliated Medicaid managed care plan—to use unified appeal and grievance processes. These integrated processes are designed to resolve misalignments between Medicare and Medicaid plan-level processes and streamline experiences for plans.

Please see the attached memorandum entitled "Contract Year (CY) 2021 Notices for Applicable Integrated Plans: “Coverage Decision Letter”, “Letter about Your Right to Make a Fast Complaint” and “Appeal Decision Letter”" from Sharon Donovan, Director, Program Alignment Group, Medicare-Medicaid Coordination Office. The memorandum describes the notices available for D-SNPs that are applicable integrated plans. 

Beginning in 2021, Dual Eligible Special Needs Plans (D-SNPs) with exclusively aligned enrollment must begin using integrated appeals and grievance processes. The flowcharts in this resource are designed to help states, health plans, and other stakeholders understand the differences between existing Medicare and Medicaid appeal and grievance processes and the new integrated appeal and grievance processes established at 42 CFR Part 422 Subpart M for fully and highly integrated D-SNPs with exclusively aligned enrollment.