In waivers and state plan amendments, states should describe proposed complaint procedures. State Medicaid agencies, Medical Care Advisory Committees, state governors and the regional and central offices of the Health Care Financing Administration all have a role in reviewing these proposals. Community organizations can direct concerns about proposed complaint procedures to all of these parties. State laws and regulations can specify procedures for plans to follow in reviewing grievances and set forth state fair hearing procedures. Under state Administrative Procedures Acts, states may be required to write formal rules about grievances and hearings and accept public comments on proposed rules.
Community organizations can urge the state to put adequate laws and regulations in place.
Contracts with managed care organizations should specify procedures plans must follow when they receive complaints. States and community organizations should make sure that managed care plans' subcontracts with providers mirror the managed care organization's contracts regarding complaint procedures. Lawsuits can clarify how due process protections apply in managed care settings. Community groups can file lawsuits when states fail to implement needed changes. Review data regarding complaints and urge sanctions for poor performers.