Designing a Complaint and Grievance System and Other Member Assistance Services Under Medicaid Managed Care

Medicaid beneficiaries enrolled in managed care arrangements have two basic sets of procedural protections when benefits are denied. The first set consists of the right to timely and adequate notice of any action affecting [a] claim for medical assistance, as well as a fair hearing in the case of any individual whose claim for medical assistance under the plan is denied or is not acted upon with reasonable promptness. The second is the right to internal grievance procedures to challenge the denial of coverage *** or payment [of medical] assistance. The Health Care Financing Administration (HCFA) is expected to delineate the specific elements of each of these procedural safeguards in a managed care environment -- as well as how the two sets of protections relate to each other -- in forthcoming regulations implementing the Balanced Budget Act (BBA) of 1997. This Issue Brief examines how state Medicaid agencies approach the issue of grievances and appeals in their contracts with managed care organizations (MCOs) furnishing comprehensive services. The source of information for this Issue Brief is the MCO contract data base maintained by the Center for Health Services Research and Policy and supported in part by the Substance Abuse and Mental Health Services Administration. As a result, this Issue Brief focuses on grievance and appeals procedures for enrollees of managed care organizations and does not address the procedural protections available to individuals who are enrolled in other forms of managed care, such as primary care case management systems

Pegram v Herdrich: Implications for Consumer Protections in Managed Care

This Report, prepared for the Substance Abuse and Mental Health Services Administration, provides a brief overview of the United States Supreme Court\u27s landmark decision in Pegram v Herdrich (hereinafter referred to as Herdrich). This report begins with a brief overview of the debate in the courts over how to distinguish between legal challenges to the conduct of managed care companies in which all state remedies are preempted by ERISA and those that may proceed under state law. It then summarizes the facts of the Herdrich case and the Court\u27s holding. The report concludes with a discussion of the implications of the decision for federal and state consumer protection legislation. A point of caution should be raised. The Herdrich decision is so new, and its implications so potentially far-reaching, that legal scholars, policy makers, lawyers, and judges undoubtedly will be pondering and debating its meaning and reach for years. However, in light of the enormous attention now focused on managed care accountability, the decision will attract a great deal of attention. Consequently, at least a preliminary analysis is warranted

Coverage Decision-Making in Medicaid Managed Care: Key Issues in Developing Managed Care Contracts

Coverage provisions are the most complex part of any managed care contract. This is particularly true for Medicaid agencies, because of important differences between Medicaid and insurance. This Issue Brief identifies general issues that should be addressed as managed care contracts are developed and drafted, and it specifically explores the challenges faced by public purchasers when drafting managed care coverage provisions

Coverage Decisions Versus the Quality of Care: An Analysis of Recent ERISA Judicial Decisions and Their Implications for Employer-Insured Individuals

This Issue Brief, prepared for the Substance Abuse and Mental Health Services Administration, examines the evolution of this framework for analyzing health claims emanating from the conduct of ERISA-covered managed care arrangements and considers its implications for the provision of treatment for mental illness and addiction disorders. Both studies and anecdotal evidence suggest that managed care companies impose particularly rigorous controls over treatment for mental illness and addiction disorders. It is therefore perhaps not surprising that legal challenges to treatment decisions frequently involve individuals with these conditions. Consequently, to the extent that courts are in fact on the verge of re-conceptualizing their approach to analyzing managed care cases under ERISA, the implications for treatment of mental illness and addiction disorders may be especially significant

Cultural Competence in Medicaid Managed Care Purchasing: General and Behavioral Health Services for Persons with Mental and Addiction-Related Illnesses and Disorders

This Issue Brief explores cultural competence. Employing the data base from the large-scale Medicaid contract analysis conducted annually by the Center for Health Services Research and Policy (CHSRP) (now CHPR), we examine the approaches that state agencies take in implementing the concept of cultural competence in the design and implementation of their managed care systems