Integrated Appeals & Grievances Demonstration in New York: Beneficiary Experience Research

Integrated Appeals & Grievances Demonstration in New York: Beneficiary Experience Research

Published: Jan 28, 2024
Publisher: Medicare-Medicaid Coordination Office
Associated Project

Research Regarding the Experience of Health Care and Other Services for Individuals Dually Eligible for Medicare and Medicaid

Time frame: 2021-2026

Prepared for:

U.S. Department of Health and Human Services, Centers for Medicare & Medicaid Services, Medicare - Medicaid Coordination Office

Key Findings
  • Professionals and family caregivers play an important role in helping beneficiaries navigate the integrated appeals process
  • About a third of beneficiaries reported that the autoforwarding of their second level appeal to IAHO eliminated the need for them to push their appeal forward.
  • Half of interviewees reported having unmet health and support needs during the appeal period that affected their health or quality of life
  • Only about half of beneficiaries interviewed recalled receiving an evidence packet from their health plan before their IAHO hearing. Because of the evidence packets’ length and complexity, several beneficiaries said they did not read the entire packet and may not have been prepared to address questions about their case at the IAHO hearing. Spanish speakers faced further challenges with understanding the evidence packets and the way they navigated the process.

This is a summary of research results about how beneficiaries dually eligible for full Medicare and Medicaid benefits experienced the Integrated Appeals and Grievances (A&G) demonstration in New York, which launched in 2020. The Integrated A&G demonstration tests the integration of the appeals and grievances process for beneficiaries enrolled in Fully Integrated Dual Eligible Special Needs Plans (FIDE SNPs). Under the demonstration, beneficiaries use one process for appealing Medicare and Medicaid coverage decisions that the plan makes, rather than navigating two separate health insurance systems. The results of this research are based on our interviews with dually eligible individuals who are enrolled in the state’s FIDE SNPs, known as Medicaid Advantage Plus (MAP) plans, and have filed at least one appeal during 2021 with their MAP plan. This research was conducted through a Centers for Medicare & Medicaid Services contract for beneficiary experience research.

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