Medicare Advantage (MA) plans must disclose grievances and appeals information to any MA plan-eligible individual upon request, including the number of disputes and outcomes.* It’s important to note that any MA plan-eligible individual may request this data, regardless of enrollment status. This allows individuals to evaluate and compare the performance of various plans effectively.

To accommodate this change, the appeal and grievance data form has been updated. Here’s a quick overview of the changes:

  • Notice update: The primary purpose of this notice is to incorporate the regulatory changes outlined in CMS-4190-F2 – CY 2023 Medicare Advantage and Part D Final Rule, which specifically impact Level 1 appeals.
  • Previous rules: In the past, when a request was withdrawn, the plan did not take any action. Consequently, withdrawn requests were still included in the total number of Level 1 appeals, alongside decisions of favorable and unfavorable outcomes. As a result, the total number of Level 1 appeals did not consistently match the total of favorable and unfavorable decisions.
  • Updated rules: Following the implementation of the new rules, if a member chooses to withdraw an appeal, the plan dismisses the appeal request. As a result, withdrawn appeals are excluded from the calculation of the total number of Level 1 one appeals. To reflect this change, the ‘What to do with Level 1 appeals’ row of the form now includes this text: “Sometimes, a member may decide to withdraw their appeal. Because the plan dismisses a withdrawn appeal, it is not included in this report.”
  • Impact of change: As a result of this change, the total number of appeals is expected to align with the combined total of favorable and unfavorable decisions.
  • Implementation timeline: Plans should implement this change quickly, ensuring completion within 60 days from the date of this notice, but no later than October 3, 2023.

ATTAC Consulting Group is nationally recognized for expertise in regulatory interpretation, and the design and operation of effective compliance programs for government and commercial health plans. Contact us about how we can put the experience, quality and rigor of our advisory services and audits to work for your plan. 

*Pursuant to §1852(c)(2)(C) of the Social Security Act and 42 CFR § 422.111(c)(3)