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Kids and Health Care: Medicaid Follows a Managed Care Model

The Medicaid Act and regulations include separate protections for individuals enrolled in managed care. The Act requires all participating managed care organizations (MCOs) to have an internal grievance process through which an enrollee may challenge a denial of coverage or payment. Each MCO must provide access to an appeals process and to the state's fair hearing process.

The MCO must resolve grievances and appeals "as expeditiously as the enrollee's health condition requires" within certain time frames established by the state. For disposition of a grievance, that time frame cannot exceed 90 days from the date the MCO receives a grievance and for resolution of an appeal, time cannot exceed 45 days. Enrollees must also have access to an expedited hearing process.

These internal procedures must satisfy constitutional standards of due process. MCOs must provide: 1) written notice of actions; 2) notice of grievance and appeal rights; 3) assistance in completing forms and filing grievances and requests for appeals; 4) information about rights to continued benefits; 5) hearing rights, such as the right to present evidence, to be represented, to examine the case file and access to an impartial decision maker; and 6) interpreter services. States may require enrollees to exhaust the MCO's internal procedures; however, it must also permit them to request a fair hearing within a reasonable time, no fewer than 20 days and no more than 90 days of the date of the MCO's resolution of the grievance or appeal. If the state does not require exhaustion, the enrollee must be allowed to request a hearing no fewer than 20 days and no more than 90 days of the date of the MCO's action.

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