Shopper Protections – Member Rights

This toolkit offers policymakers, together with State Medicaid Company employees, and advocates, with rules and corresponding template language to develop State Medicaid Company Contracts (SMACs) which might be attentive to the wants of the dually eligible populations they serve. Stakeholders are inspired to make use of this device to advance their priorities by tailoring the parts which might be most acceptable for his or her state’s built-in environments.

Elements IV and V of the toolkit present a sturdy dialogue on shopper protections inside D-SNPs, together with Member Engagement and Help (e.g., Enrollee Advisory Committees and Ombuds Applications), and Member Rights (e.g., Sustaining Protection and Appeals and Grievances). Half I of this toolkit covers Eligibility and Enrollment in addition to Supplemental Advantages, Half II of this toolkit focuses on Advertising and Communications, and Half III of this toolkit encompasses Care Coordination.

Drawing from Justice in Getting older’s D-SNP Problem Temporary, we heart the experiences of dually eligible enrollees and spotlight the challenges confronted by this inhabitants in navigating their medical insurance protection. To information the dialogue, we reference the Justice in Getting older Guiding Rules, a core set of values and objectives that decision for strong shopper protections, well being fairness, person-centered care, and extra oversight and accountability in integration fashions. Justice in Getting older will launch subsequent sections of this toolkit in 2026.

This publication highlights finest practices drawn from D-SNP mannequin contracts and Monetary Alignment mannequin contracts. For this device, in situations the place present SMAC language just isn’t publicly out there or has not but been written, Justice in Getting older offers prompt template language to assist advance key shopper protections and rules.

Sustaining Protection and Entry to Providers and Suppliers

Each deeming and continuity of care protections function essential methods to allow enrollees to keep up protection and entry to companies and suppliers.

Deeming Protections

Biking out and in of Medicaid enrollment or “Medicaid churn” stays a significant impediment to sustaining entry to take care of folks dually eligible. Analysis demonstrates that folks dually eligible mostly lose Medicaid protection for administrative causes reasonably than adjustments in monetary or categorical eligibility for state Medicaid packages.^[1] Medicaid churn may cause enrollees to lose eligibility ensuing of their disenrollment from one D-SNP to enrollment in one other. To mitigate Medicaid churn and assist folks dually eligible in retaining their suppliers and advantages with out interruptions throughout disruptions and transitions, states can leverage SMACs to make sure D-SNPs present deeming protections.

The Impression of the Price range Reconciliation Act of 2025 (H.R. 1)

The Price range Reconciliation Act of 2025 or H.R. 1 will doubtless exacerbate Medicaid churn among the many dually eligible inhabitants. For instance, the regulation halts the Streamlining Medicaid Eligibility & Enrollment Guidelines for ten years. This can make it more durable for older adults to get and keep Medicaid protection by permitting states to keep up bureaucratic necessities, akin to complicated earnings verification paperwork and frequent renewals that presently stop eligible folks from gaining and sustaining protection. Older adults who depend on Medicaid to assist pay their Medicare premiums and cost-sharing by Medicare Financial savings Applications can even proceed to face this purple tape, placing hundreds of thousands susceptible to shedding important monetary assist that makes Medicare inexpensive.^[2] Whereas extra eligibility verifications and work requirement provisions throughout the regulation exclude folks dually eligible, confusion, misinformation, and system pressure might trigger eligible people to inappropriately lose protection. Within the context of H.R. 1, SMACs are an essential device for states to leverage to safe continuity of care and deeming protections for dually eligible people. For extra data on the impacts of H.R. 1 on dually eligible people, see the Justice in Getting older Medicaid Protection collection.

Guiding Precept

Built-in fashions present strong shopper protections.

Supporting Precept

Built-in fashions make the most of coverage levers to attenuate disruptions in care.

Federal Necessities

Deeming intervals enable D-SNP enrollees to remain enrolled with entry to plan advantages and care administration throughout lapses in Medicaid protection for a decided interval. In response to 42 CFR 422.52(d), CMS permits D-SNPs to offer deeming intervals from a minimal of 30 days to 6 months for dually eligible people who lose enrollment however are anticipated to fulfill the eligibility standards for Medicaid inside a six-month interval.

When D-SNPs present a deeming interval, they’re required to use the coverage constantly and inform all enrollees. Plans should additionally present written discover to enrollees concerning their lack of particular wants standing inside 10 calendar days of studying concerning the enrollee’s lack of standing. If D-SNPs make adjustments to the deeming coverage mid-year, they need to observe notification necessities outlined in 42 CFR 422.111(d) and 422.2267(e)(9). In response to 42 CFR 422.74, D-SNPs are required to disenroll enrollees who don’t reestablish their eligibility throughout the designated deeming interval and supply a minimal of 30 days’ advance discover of disenrollment.

Whereas D-SNPs should present Medicare associated advantages together with plan supplemental advantages throughout the deeming interval, plans are usually not required to offer protection of Medicaid associated advantages.[3] In consequence, when members expertise a Medicaid eligibility lapse, they could incur cost-sharing for care obtained throughout the deeming interval.

SMAC Suggestion

States ought to require D-SNPs to supply deeming protections for six months to stop plan disenrollment attributable to non permanent lack of Medicaid eligibility.

Template Language

California and North Dakota

To make sure that members retain their D-SNP protection throughout non permanent lapses in Medicaid protection, California and North Dakota each require D-SNPs to offer deeming protections for at the very least three months.

• For these members who’ve misplaced Medicaid eligibility, the D-SNP Contractor is required to keep up enrollment for such members for at the very least a three-month deeming interval following notification that the member misplaced Medicaid eligibility. This requirement doesn’t preclude the D-SNP Contractor from providing an extended deeming interval. The D-SNP Contractor ought to inform its State Medicaid Company employees contact of the deeming interval that it’ll present.^[4]
• As allowed by CMS steerage, MAO shall present deemed continued eligibility for a minimal three (3) months to keep up the continuity of care of people that not meet D-SNP eligibility standards attributable to a short lived lack of Medicaid eligibility.^[5]

Virginia, Indiana, and Pennsylvania

To assist members retain their D-SNP protection during times of non permanent lack of Medicaid protection, these three states require D-SNPs to supply deeming protections for six months.

• When a member loses Medicaid eligibility and the Contractor determines the person is more likely to regain Medicaid eligibility inside six months of the termination date, the Contractor should retain the Member for the total six months.[6]
• The MAO shall present “Deemed Continued Eligibility” for six (6) months to keep up the utmost continuity of care for people that not meet D-SNP eligibility standards attributable to a short lived lack of Medicaid eligibility.^[7]
• As allowed by CMS steerage, D-SNPs shall present deemed continued eligibility for six months to keep up steady protection when a member briefly loses Medicaid eligibility.^[8]

Extra SMAC Language

The Contractor shall present all relevant lined advantages, together with Medicaid companies, at no extra price to the enrollee, all through the deeming interval. The Contractor will likely be financially liable for cost of Medicaid-covered companies throughout the deeming interval with a view to guarantee continuity of protection and to stop cost-sharing by the enrollee.^[9]

Continuity of Care Protections

Individuals dually eligible typically depend on long-standing relationships with main care, specialty, and sturdy medical gear suppliers, and lots of are recipients of complicated remedies and drug regimens. A transition to a brand new plan, which can contain adjustments in supplier networks or service protection, can create critical disruptions in care.

To restrict these dangers, contract language might be leveraged to safeguard continuity of care by two key protections. First, enrollees ought to keep entry to present companies and pharmaceuticals throughout an outlined transition interval after enrollment in a D-SNP. Second, enrollees ought to be capable to proceed seeing their present suppliers who are usually not but within the plan’s community. D-SNPs will need to have mechanisms to pay non-network suppliers throughout this era and actively work to deliver them into the community. If these efforts are unsuccessful, a transparent course of ought to enable enrollees to safe approval to proceed care with their trusted suppliers.

Guiding Precept

Built-in fashions present strong shopper protections.

Supporting Precept

Built-in fashions make the most of coverage levers to attenuate disruptions in care.

Federal Necessities

Along with making certain entry to primary advantages to all enrollees outlined in 42 CFR 422.101, D-SNPs should additionally abide by the continuity of care necessities in 42 CFR 422.112(b). These necessities embrace plan approval of prior authorization requests for enrollees present process a course of remedy for so long as the remedy is medically mandatory, and a 90-day minimal transition interval for any lively course(s) of remedy when an enrollee has enrolled in a plan after beginning a course of remedy, even when the service is furnished by an out-of-network supplier.^[10]

Moreover, for Half D lined medicines, plans should present enrollees with a short lived transition refill for the primary 90 days of the plan 12 months starting on the enrollee’s first efficient date of protection.^[11] Per 42 CFR 422.100(l)(2)(iii), plans should additionally guarantee a 90-day transition interval for sturdy medical gear (DME) the place enrollees are assured the provision and repairs of their DME.

SMAC Suggestion

States can and may implement strong continuity of care protections that go above and past the federal minimal. For instance, states ought to implement a 12-month interval of transition, from the efficient date of the enrollment, requiring D-SNPs to cowl out-of-network main care suppliers, specialists, DME suppliers, long-term companies and helps, and pharmacies.

To make sure enrollees perceive and are totally knowledgeable of their continuity of care protections, states also needs to require plans to offer the plan continuity of care insurance policies within the member handbook and different member notices that meet language and accessibility codecs.^[12] Moreover, states ought to require D-SNPs to assign a Main Care Supervisor to assist enrollees with accessing continuity of care protections.^[13]

Moreover, when a brand new enrollee joins a plan, states ought to require plans to proactively interact and encourage their non-network suppliers to affix the plan’s community with a view to cut back disruptions in care. States also needs to require plans to think about continuity of care goals earlier than decreasing service entry.

Template Language

California

California requires D-SNPs to offer a 12-month continuity of care interval from the date of enrollment for main care suppliers and specialists with present relationships with enrollees. Moreover, the state requires plans to make sure enrollees have entry to their DME objects, provides, and suppliers, for greater than a 90-day interval, and till the plan is ready to assess and supply the enrollee with the DME provide or merchandise by an in-network supplier.^[14]

• D-SNP Contractor should present Members with the next:
  1. A 12-month continuity of care interval from the date of the Member’s Enrollment within the D-SNP, for main and specialty suppliers with whom the Member has a pre-existing relationship and who’re keen to work with the D-SNP Contractor; and
  2. Entry to Medically Obligatory Medicare-covered Sturdy Medical Tools and medical provides.[15]

California requires D-SNPs to just accept continuity of care requests from enrollees, licensed representatives, and suppliers who’re eligible for continuity of care. Moreover, the state requires plans to just accept continuity of care requests through phone and in line with enrollee preferences and can’t obligate requester to submit requests through paper or digital type. D-SNPs are additionally required to just accept retroactive continuity of care requests and pay claims accordingly.

• Members, their licensed representatives, or their suppliers might make a direct request to a D-SNP for continuity of care.
• D-SNPs should, at a minimal, settle for requests for continuity of care over the phone, in line with the requestor’s desire, and should not require the requester to finish and submit a paper or pc type.
• D-SNPs should settle for and approve retroactive requests for continuity of care and pay claims that meet all continuity of care necessities famous above, excluding the requirement to abide by the D-SNP’s utilization administration insurance policies.^[16]

Massachusetts

To take care of continuity of care for brand spanking new enrollees, Massachusetts proactively engages with non-network suppliers to encourage them to develop into credentialed.

• The Contractor shall make sure that finest efforts are made to contact and contract with non-network suppliers, together with, throughout the first ninety (90) days of an Enrollee’s Membership within the Contractor’s D-SNP, such suppliers and prescribers that are offering companies to Enrollees throughout the preliminary continuity of care interval, and supply them with data on changing into credentialed, in-Community Suppliers. If the supplier doesn’t be a part of the community, or if the Enrollee doesn’t choose a brand new in-Community Supplier by the top of the ninety (90) day interval or after the Individualized Care Plan is developed, the Contractor shall select one for the Enrollee.^[17]

When evaluating LTSS requests, Massachusetts requires plans to think about continuity of care goals.

• In evaluating requests for LTSS, the Contractor shall think about continuity of care. If a service, stage of service, or gear has been a part of the Enrollee’s life routine over an prolonged interval and is integral to their total care and independence construction, any denial or discount in quantity, length, frequency, or scope of that service/gear/provide should be supported within the ICP to make sure that such adjustments won’t trigger diminished means for unbiased dwelling and be in line with the general objectives and wishes of the enrollee as expressed within the ICP.^[18]

Appeals and Grievances

For folks dually eligible and their caregivers, navigating the bifurcated Medicare and Medicaid appeals and grievances processes provides undue stress and confusion, typically impeding well timed entry to care. Whereas built-in fashions present some promise with streamlining and simplifying these processes, extra oversight is required to make sure that D-SNPs are usually not simply routinely denying protection for medically mandatory care. Latest knowledge has revealed a regarding pattern of excessive charges of denials of protection and prior authorization in Medicare Benefit (MA).^[19] To ensure that folks dually eligible to entry the medically mandatory care they want once they want it, D-SNPs ought to embrace strong shopper protections and transparency necessities to make sure claims are processed well timed and pretty adjudicated.

Built-in Appeals and Grievances Processes

Guiding Precept

Built-in fashions enhance entry to care and member expertise throughout the various dually eligible inhabitants.

Supporting Precept

Members can entry their Medicare and Medicaid advantages immediately.

Federal Requirement

MA organizations should observe the federal rules overlaying well being care and drug associated appeals or group determinations outlined in 42 CFR 422.566 and §423.566. Moreover, MA plans should observe necessities for well being care and drugs associated grievances outlined in 42 CFR 422.564 and §423.564. Per 42 CFR §§ 422.629-634, D-SNPs that function as relevant built-in plans akin to FIDE SNPs, HIDE SNPs, and CO D-SNPs that meet particular necessities, are required to combine their appeals and grievances processes. This consists of offering eligible enrollees who file appeals well timed with a continuation of advantages on the first stage of enchantment whereas the built-in plan reconsideration is pending.^[20] Whereas 42 CFR 422.629(g) requires D-SNPs with built-in appeals and grievances to offer written acknowledgement of receipt of a grievance or enchantment, the regulation doesn’t present set timeframes. Since most D-SNPs are usually not required to combine their appeals and grievance processes, the SMAC can function a device to push for enhanced integration.

SMAC Suggestions

States ought to require all D-SNPs to share appeals and grievances plan stage knowledge associated to Medicare Half C, D, and the place relevant, Medicaid companies. States also needs to work to make this knowledge publicly out there to make sure transparency and accountability. Moreover, for D-SNPs not required to combine their appeals and grievances processes, states can require plans to offer each Medicare and Medicaid appeals and grievances data within the enrollee handbook and different shopper supplies.^[21]

For D-SNPs with built-in appeals and grievances processes, states ought to transcend the federal minimal and require plans to combine the appeals processes in any respect ranges.^[22] Just like the New York state built-in appeals and grievances mannequin profiled on this toolkit, states can require built-in appeals processes to proceed as follows: if the plan upholds its choice, the enchantment could be routinely forwarded to the second stage of the enchantment by the state workplace of administrative hearings. Enrollees who disagree with the choice, would be capable to enchantment to the Medicare Appeals Council and at last the Federal District Court docket. Every stage of enchantment would adjudicate each Medicare and Medicaid appeals.[23]

Moreover, states ought to require D-SNPs with built-in processes to include Half D in built-in enchantment and grievance efforts to make sure enrollees who want entry to prescription medicines can make the most of a streamlined course of to resolve denials of protection and utilization administration restrictions well timed. Underneath an built-in appeals and grievance course of that comes with Half D, enrollees would provoke one streamlined remedy enchantment or grievance course of, and the duty would fall on the D-SNP to deal with whether or not the remedy is beneath Half D or Medicaid protection.

For eligible enrollees, D-SNPs with built-in appeals and grievances processes must be required to offer the continuation of advantages pending the enchantment in any respect ranges of the appeals course of and permit enrollees to proceed receiving protection for the medical service or merchandise being denied whereas the enchantment is pending.^[24] If the plan’s choice is upheld, the SMAC ought to specify that enrollees won’t be held accountable for the prices of companies obtained pending the enchantment choice.

Along with requiring D-SNPs to combine plan appeals and grievances supplies in any respect ranges and guarantee these meet the language and accessibility necessities outlined within the Justice in Getting older Advertising Communications SMAC toolkit, states ought to work with plans to make sure built-in enchantment notices are uniformly timed with scheduled state hearings when relevant. States also needs to specify the timeframes of when plans are required to offer enrollees with written acknowledgement of the grievance or enchantment.^[25]

Template Language

Ohio

Ohio requires D-SNPs to report on grievances and appeals knowledge and submit an evaluation of traits and any actions taken by the plan. As well as, the state requires plans to report encounter knowledge on Medicare and Medicaid companies for dually eligible members.

• The D-SNP should submit enchantment and grievance exercise at the very least month-to-month in an digital knowledge file format pursuant to the State Attraction and Grievance file submission specs stipulated on this contract.
• As a part of the D-SNP’s report submission, the plan should embrace the evaluation of particular person and mixture outliers and traits and establish the plan’s actions taken in response.^[26]
• The D-SNP should accumulate knowledge on companies furnished to members by a claims system and should report encounter knowledge to the state. For twin profit members, the info should embrace each Medicare and Medicaid companies. The D-SNP should submit encounter knowledge electronically to the state as specified on this contract.^[27]
• The D-SNP should conduct root trigger evaluation of authorization denials and appeals and develop a focused plan to lower inappropriate denials and guarantee ease of enchantment of medical necessity denials.^[28]

New York

The New York Built-in Appeals and Grievances Demonstration requires taking part D-SNPs to combine their appeals and grievances processes and supply the continuation of advantages pending an enchantment in any respect ranges.[29]

• Taking part D-SNPs will apply the built-in grievance course of described in 42 CFR § 422.630 to all plan-level grievances, whether or not referring to Medicare or to Medicaid.
• The plans can even apply the built-in protection dedication and reconsideration course of described at 42 CFR § 422.629 and §§ 422.631 by 422.634.
• For appeals subsequent to the plan stage, a streamlined post-plan course of will exchange the separate Medicare and Medicaid processes. This course of will guarantee all protections in statute, regulation, and regulatory steerage for each Medicare and Medicaid appeals processes.
• Continuation of advantages for all prior-approved Medicare and Medicaid advantages which might be terminated or modified, pending inside taking part plan appeals, second stage appeals at Workplace of Administrative Hearings (OAH), and third stage appeals at Medicare Appeals Council should be offered if the unique enchantment is requested to the taking part plan inside ten (10) calendar days of the discover’s postmark date (of the choice that’s being appealed) or by the supposed efficient date of the Motion, whichever is later.
• Within the case of an enchantment to the Medicare Appeals Council, the member will need to have obtained continuation of advantages throughout earlier stage of appeals and file the enchantment with OAH inside ten (10) calendar days of the OAH choice with a view to obtain continuation of advantages throughout the enchantment to the Medicare Appeals Council. If the taking part plan’s motion is upheld, the member shall not be accountable for the price of any continued advantages.

California

For D-SNPs required to combine their appeals and grievances processes, California mandates that plans have procedures to make sure compliance with the acknowledgement of grievances, and the decision of appeals, throughout the required timeframes. Moreover, the state requires plans to ascertain procedures to tell enrollees of their honest listening to rights.

• For built-in appeals, D-SNP Contractor will need to have the next:
  • Process to offer written acknowledgement of receipt of all built-in appeals inside 5 (5) calendar days in accordance with 42 CFR § 422.629(g).
  • Process to resolve customary built-in appeals as expeditiously because the member’s well being situation requires however to not exceed 30 calendar days from the date of receipt of the request in accordance with 42 CFR § 422.633(f)(1).
  • Process to tell members of their rights to a state listening to and embrace essentially the most present state listening to type when the next necessities are met:
    • The denied built-in enchantment choice just isn’t for a Medicare-only service or profit; and
    • The built-in enchantment pertains to a denial, in complete or partly, of a Medicaid service or profit, together with circumstances the place there may be an overlap of Medicare and Medicaid. [30]

Extra SMAC Language

The state will share data (e.g., Administrative Listening to Contacts, updates about honest listening to scheduling and/or delays, shopper written supplies about tips on how to request a good listening to, and so on.) with the D-SNP Contractor concerning the state listening to procedures. The D-SNP Contractor is liable for aligning built-in enchantment notices to make sure enrollees are offered well timed notification about their honest listening to rights for Medicaid state plan lined companies and overlapping Medicare and Medicaid companies.^[31]

Extra on Continuation of Advantages

The common Medicare Benefit appeals course of doesn’t embrace a requirement for plans to offer the continuation of advantages whereas an enchantment is pending (also referred to as “assist persevering with” or “assist pending”).^[32] D-SNPs with built-in appeals and grievances processes are completely different. Per 42 CFR 422.632, these D-SNPs are required to offer the continuation of advantages on the plan reconsideration stage whereas the enchantment is pending to eligible enrollees who meet the standards outlined in 42 CFR 422.632(b). Whereas D-SNPs might not pursue restoration for prices of companies furnished pending the built-in reconsideration, plans might get well prices for Medicaid companies after the built-in reconsideration choice is closing.^[33]

Appeals and Grievances: Complete Shopper Help

Guiding Precept

Built-in fashions enhance entry to care and member expertise throughout the various twin eligible inhabitants.

Supporting Precept

Members can entry their Medicare and Medicaid advantages immediately.

Federal Requirement

Per 42 CFR 422.562(a)(5), all D-SNPs are required to help enrollees in accessing Medicaid advantages and resolving grievances. This consists of offering enrollees with cheap help in navigating Medicaid appeals and grievances. Plans with built-in appeals and grievances processes should take extra steps to fulfill this requirement.^[34] CMS permits plans to offer help in a number of methods together with referring enrollees to exterior specialists akin to Ombuds Applications, State Well being Insurance coverage Help Applications (SHIPs), and others.^[35] As Medicare Benefit plans, D-SNPs are required to function a name heart that adheres to the requirements outlined in 42 CFR §§ 422.111(h)(1) and 423.128(d)(1).

SMAC Suggestions

States ought to require D-SNPs to include help with accessing Medicare and Medicaid lined companies, together with carved out and supplemental advantages, as a care coordination duty assigned to a particular position akin to a Care Supervisor. The help offered by the Care Supervisor would embody serving to enrollees with navigating the Medicare and Medicaid grievances and appeals processes, whether or not these processes are built-in or not.^[36]

Along with requiring plans to stick to the accessibility and language rules outlined within the Justice in Getting older Advertising and Communications SMAC Toolkit, states ought to require plans to incorporate the contact data of the State and Federal Ombuds Applications and the State Well being Insurance coverage Help Applications (SHIPs) in all enchantment notices.

Template Language

Washington

Washington requires D-SNPs to develop insurance policies and trainings for plan personnel to help enrollees with Medicare and Medicaid appeals and grievances processes. The state additionally requires plans to create procedures to work with behavioral well being Ombuds within the state and description how plans will entry companies from the state and federal Ombuds packages. The state additionally requires D-SNPs to create a referral mechanism for grievances associated to behavioral well being companies.^[37]

• The Contractor will develop insurance policies and procedures round helping members in accessing grievance and enchantment methods for each Medicare and Medicaid. These shall be offered to the state upon request.
• Trainings ought to clearly define tips on how to help members with accessing grievance methods.
• The Contractor will coordinate with all contracted D-SNPs and behavioral well being companies organizations (BHSO) within the state to develop contact names and a referral course of for use by their Grievance and Appeals groups for steering members and suppliers for grievances referring behavioral well being to the suitable sources. The referral should embrace steps for a heat handoff as mandatory to make sure immediate evaluate. The Contractor shall put together and supply a report upon request of all grievances that have been obtained and referred to the BHSO.
• The Contractor course of should embrace tips on how to entry state and federal ombuds companies.
• The place the member is aligned for Behavioral and Bodily Well being companies the Contractor shall monitor and report all grievances for twin eligible members. This report shall be made out there upon request.

Massachusetts

Massachusetts requires D-SNPs to function a name heart helpline particular to “Protection Determinations and Appeals.” Not like different plan customer support strains, the SMAC specifies that the Protection Determinations and Appeals helpline could have educated plan representatives out there to debate Medicare and Medicaid enchantment points and take protection dedication and redetermination requests for each packages.^[38]

• The Contractor shall function a toll-free name heart with dwell customer support representatives out there to reply to suppliers or enrollees for data associated to requests for protection beneath Medicare or Medicaid, and Medicare and Medicaid Appeals (together with requests for Medicare exceptions and prior authorizations).
• The Contractor shall present, through its toll-free name facilities, alternatives for enrollees to request for Medicare and Medicaid lined advantages and companies, together with Medicare protection determinations and redeterminations.

As a part of the necessities for disseminating “Advertising, Outreach and Enrollee Communications Supplies,” Massachusetts mandates that D-SNPs present enrollees with details about how they’ll entry help with submitting appeals and grievances, the continuation of advantages throughout appeals, and tips on how to establish representatives to obtain written notices concerning denials, terminations or reductions in companies.^[39]

• Methods to file grievances and inside and exterior appeals, together with:
  • Grievance, enchantment, and honest listening to procedures and timeframes;
  • Toll free numbers that the enrollee can use to file a grievance or an enchantment by cellphone;
  • Methods to entry help within the submitting course of;
  • The best to file a grievance straight with the State, how to take action, and the State contact data; and
  • An announcement that if the enrollee information an enchantment or request for state honest listening to throughout the timeframes specified for submitting and when requested by the enrollee, advantages will proceed on the plan stage for all advantages;
  • How the enrollee can establish who the enrollee desires to obtain written notices of denials, terminations, and reductions;
  • Methods to get hold of help with the appeals processes by the Enrollee Providers Representatives (ESR) and different help mechanisms because the State might establish, together with an Ombuds;

Massachusetts requires D-SNPs to place in place a mechanism to just accept grievances and appeals filed orally.[40]

• Settle for grievances filed both orally or in writing; and
• Settle for inside appeals filed both orally or in writing inside 60 calendar days from the discover of Antagonistic Motion specified on this contract offered that if an inside enchantment is filed orally, the Contractor shall not require the enrollee to submit a written, signed inside enchantment type subsequent to the enrollee’s oral request for an enchantment. Inner appeals filed later than 60 days from the discover of antagonistic motion could also be rejected as premature.
• The Contractor shall ship a written acknowledgement of the receipt of any grievance or inside enchantment to enrollees and, if an appeals consultant filed the grievance or inside enchantment, to the appeals consultant and the enrollee inside one enterprise day of receipt by the Contractor.

Extra SMAC Language

To make sure compliance with rules at 42 CFR §§ 422.562(a)(5) and 422.629(e), the D-SNP Contractor will assign to the Care Supervisor position the duty to offer members with cheap help with Medicare and Medicaid appeals and grievances together with for carved out advantages. If the member accepts the help, the Care Supervisor ought to help the member as wanted, akin to figuring out and reaching out to a Medicaid fee-for-service level of contact, offering help in submitting an enchantment or grievance, serving to to acquire documentation to assist a request for Medicaid enchantment or grievance, or finishing paperwork that could be wanted in submitting an enchantment or grievance.^[41]

Endnotes

1. For a broader dialogue on Medicaid churn and the dually eligible inhabitants, see Lakhmani, Erin Weir et al., “Stopping and Addressing Pointless Medicaid Eligibility Churn Amongst Dually Eligible People: Alternatives for States,” Built-in Care Useful resource Heart (March 2022) (Accessed September 4, 2025). ↑

2. An Act to offer for reconciliation pursuant to title II of H. Con. Res. 14, Pub. L. No. 119-21, §§71101, 71102, 44101 (2025) [“H.R. 1”]. ↑

3. CMS, “Steering on Medicaid Unwinding for Impacted Enrollees,” (June 7, 2023) (Accessed September 5, 2025); see additionally CMS, “Chapter 2-Medicare Benefit Enrollment and Disenrollment,” part 50.2.5 (Rev. August 15, 2023) (Accessed September 5, 2025). ↑

4. CA Division of Well being Care Providers (DHCS), Boilerplate 2026 SMAC EAE D-SNP, pg. 14. See additionally DHCS, Deeming Truth Sheet: In California, Medicare Benefit Twin Eligible Particular Wants Plans (D-SNPs) are required to keep up D-SNP enrollment for members who’ve misplaced Medi-Cal eligibility for a minimal deeming interval of three months. This coverage ensures that members retain their D-SNP protection throughout non permanent lapses in Medi-Cal eligibility, permitting time to reestablish Medi-Cal eligibility with out shedding entry to important Medicare companies. D-SNPs might present a deeming interval of three to 6 months. ↑

5. North Dakota Division of Well being and Human Providers, 2025 SMAC Between the State of North Dakota, Division of Well being and Human Providers, Medical Providers Division and Medicare Benefit Group, pg. 12. ↑

6. Commonwealth of Virginia Division of Medicare Help, D-SNP 2025 Contract. ↑

7. Indiana Medicaid, Indiana 2024 SMAC, p. 17. ↑

8. Pennsylvania Division of Human Providers, 2025 MIPPA Contract, p. 4. ↑

9. To encourage D-SNPs to cowl Medicaid companies throughout deeming intervals, see retroactive protection ideas contained in ICRC, Stopping and Addressing Pointless Medicaid Eligibility Churn Amongst Dually Eligible People: Alternatives for States, March 2022. ↑

10. 42 CFR 422.112(b)(8) ↑

11. See CMS, “Medicare Prescription Drug Profit Guide chapter 6,” §30.4.4 (Rev. January 15, 2016) (Accessed October 4, 2025). ↑

12. For a sturdy dialogue of language and accessibility necessities for SMACs, see “Language and Accessibility” in Justice in Getting older, “Advertising and Communications for D-SNP State Medicaid Company Contracts,” (Could 5, 2025). ↑

13. For a sturdy dialogue of the position of the Main Care Supervisor, see Justice in Getting older, “Care Coordination for D-SNP State Medicaid Company Contracts,” (August 19, 2025). ↑

14. California Division of Well being Care Providers, “CALAIM Twin Eligible Particular Wants Plans Coverage Information,” pp. 45 – 50 (2025) (Accessed October 4, 2025). ↑

15. California Division of Well being Care Providers, “Boilerplate 2025 SMAC Solely Aligned Enrollment D-SNP,” Exhibit A, Attachment 1 at 12, (2025) (Accessed October 4, 2025). ↑

16. DHCS, supra be aware 14, at 47. ↑

17. Massachusetts Government Workplace of Well being and Human Providers (EOHHS), “2023 One Care Mannequin Contract,” p. 144. ↑

18. Ibid p. 210. ↑

19. HHS, Workplace of Inspector Common, “Some Medicare Benefit Group Denials of Prior Authorization Requests Elevate Issues About Beneficiary Entry to Medically Obligatory Care,” (April 2022) (Accessed August 6, 2025); see additionally Biniek, Jeannie Fuglesten, et al., “Medicare Benefit Insurers Made Almost 50 Million Prior Authorization Determinations in 2023,” Kaiser Household Basis, (January 28, 2025) (Accessed August 6, 2025). ↑

20. 42 CFR 422.632 ↑

21. For a sturdy dialogue on built-in supplies and processes, see Justice in Getting older, “D-SNP SMAC Template Toolkit: Advertising and Communications,” (Could 5, 2025). ↑

22. This language was tailored from Shyken-Rothbart, Beth and Derek Ayeh, “Built-in Appeals are Important, However Challenges Stay,” Well being Affairs (September 19, 2022) (Accessed August 11, 2025). ↑

23. This language was tailored from the outline of the New York State Built-in Appeals and Grievances Demonstration as outlined in Snow, Kimberly I., et al., “Monetary Alignment Initiative New York Built-in Appeals and Grievances Demonstration First Temporary Report,” at ES-1 (March 2022) (Accessed August 20, 2025). ↑

24. Shyken-Rothbart, Beth and Derek Ayeh, supra be aware 22. ↑

25. This language was tailored from the challenges of the New York State Built-in Appeals and Grievances Demonstration as outlined in Snow, Kimberly I., et al., supra be aware 23, at §3.2.2. ↑

26. This language was tailored from Ohio Division of Medicaid, “Subsequent Era MyCare Ohio Supplier Settlement for MyCare Ohio Plan,” Appendix A, p. 56, (Accessed August 13, 2025). Not out there on-line. ↑

27. Id. at 296. ↑

28. Id. at 122. ↑

29. CMS, “Memorandum of Understanding between the Facilities for Medicare and Medicaid Providers (CMS) and the New York State Division of Well being to Function Built-in Grievance and Appeals Processes for Sure Built-in Medicare and Medicaid Plans,” (Accessed August 13, 2025). ↑

30. California Division of Well being Care Providers (DHCS), “Boilerplate 2026 SMAC Solely Aligned Enrollment D-SNP,” Exhibit A, Attachment 1 at 18-19, (Accessed August 14, 2025). ↑

31. See Snow, et al., supra be aware 25. ↑

32. 42 CFR 422.566; see additionally CMS, “Elements C & D Enrollees Grievances, Group/Protection Determinations, and Appeals Steering,” (Efficient date November 18, 2024) (Accessed September 2, 2025). ↑

33. 42 CFR 422.632(d); for a evaluate of the Medicaid continuation of advantages rules, see 42 CFR 438.420(d); and Medicaid and CHIP Fee and Entry Fee, “Chapter 2: Denials and Appeals in Medicaid Managed Care,” p. 27 (March 2024) (Accessed September 3, 2025). ↑

34. 42 CFR 422.629(e). ↑

35. CMS, “Medicare Managed Care Guide Chapter 16-B: Particular Wants Plans,” § 20.2.10.1 at 38, (Rev. 131; Issued: 11-22-24), (Accessed August 15, 2025). ↑

36. For a sturdy dialogue on the Care Supervisor position inside Care Coordination, see the Justice in Getting older, “D-SNP SMAC Template Toolkit: Care Coordination,” (August 2025). ↑

37. Washington State Well being Care Authority, “Amended and Restated State Medicaid Company Contract,” §1.12 at 44 (Revised March 13, 2024) (Accessed August 18, 2025). ↑

38. Massachusetts Government Workplace of Well being and Human Providers (EOHHS), supra be aware 17, §2.11.3 at 231. ↑

39. Id. §2.12.5. at 236 – 238. ↑

40. Id. §2.13.1.3. at 243 – 244. ↑

41. This language was tailored from California DHCS, supra be aware 32; see extra dialogue across the Care Supervisor position in Justice in Getting older, supra be aware 13, at 15. ↑