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


Project Overview


To better monitor and address potential inequities in beneficiary access to care.

Project Motivation

Complement the Medicaid and CHIP Payment and Access Commission’s ongoing internal work examining how state and federal officials monitor denials and the appeals process to ensure enrollees receive appropriate access to care. 

Prepared For

Medicaid and CHIP Payment and Access Commission

Medicaid and CHIP Payment and Access Commission (MACPAC) is exploring whether the Medicaid managed care appeals process offers a meaningful and accessible opportunity for beneficiaries to appeal plan decisions. 
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 potentiall 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 is writing a report on the major findings from the focus groups and identify remaining knowledge gaps.

Related Staff

Patrick McGowan

Patrick McGowan

Senior Researcher

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Amy Wodarek O’Reilly

Amy Wodarek O’Reilly

Principal Managing Consultant; Co-Lead, Health Human-Centered Design Practice

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