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. Educate consumers about how to document service denials and how to get legal help. Community organizations can educate beneficiaries to put important requests for services in writing and to ask for responses in writing when care is not forthcoming.