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. A plan's internal grievance procedures will violate Medicaid beneficiaries' rights if they delay access to a fair hearing and final state-level decision beyond 90 days. In a Tennessee case, the court found that the 90-day clock starts running as soon as a beneficiary contests a decision with either the managed care plan or the state.
Some states treat complaints as a request to disenroll.
Proper complaint procedures hold managed care organizations accountable for providing services for which the state and federal governments have already paid. From the individual beneficiary's point of view, disenrolling might be the fastest way to obtain a disputed service. However, simply permitting disenrollment fails to hold managed care organizations accountable for care and enables them to keep payments although they have not delivered services. Some states are not integrating complaint channels. States may route problems to hotlines or ombudsprograms for informal mediation without instructing beneficiaries that they may also file formal grievances and hearing requests.