Member handbooks sometimes describe complex in-plan grievance procedures that take longer than 90 days to complete. Notices may not explain that benefits can continue pending resolution of complaints about service reductions or terminations. Sometimes, managed care organizations send letters to enrollees stating that a course of treatment is going to end on a certain date. These letters may not inform enrollees of their rights to dispute this decision and to request and receive continued care until the matter is resolved. If the dispute resolution process is protracted, Medicaid beneficiaries' health can be severely harmed unless services continue.
States rely too heavily on managed care organizations to settle disputes.
Some states argue that Medicaid beneficiaries do not have a right to a state-level Medicaid fair hearing about a managed care organization's decisions because these are medical decisions made by a contractor, not by the state. Managed care organizations' internal complaint processes may delay access to an impartial hearing. Managed care organizations may not have good systems for handling complaints. In some instances, members who complain are routed endlessly to member service departments, and their complaints are not treated as formal grievances. In other instances, members may become frustrated before they complete a multi-tiered grievance process that involves numerous personnel.