Differentiating between grievances and appeals for Medicare enrollees

Under Medicare law, Medicare Advantage plans and stand-alone Part D plans must follow certain rules when enrollees disagree with plan healthcare coverage determinations. There are two distinct methods for raising issues when enrollees are dissatisfied with their Medicare determinations or actions—grievances and appeals. Knowing the difference between grievances and appeals is essential to safeguarding the enrollee’s Medicare rights.

Grievances

A grievance is any communication verbal or written, from a member expressing dissatisfaction with any aspect of the Medicare Advantage Plan or any contracted provider's activities or behavior regardless of whether any remedial action is requested.

Reasons a member might file a grievance may include:

• Quality of care.

• Wait times for scheduling appointments or time spent in the waiting room during appointments.

• The way the doctor or other staff behaved.

• Not being able to reach someone by phone or get information needed.

• The cleanliness or condition of the doctor's office or pharmacy.

Appeals

An appeal is a complaint made by the member if they disagree with the plan sponsor's decision to deny a request for coverage of health care services or prescription drugs or payment for services or drugs they already received. The member can also make an appeal if they disagree with the plan sponsor's decision to stop services they are receiving.

For example, a member can file an appeal when:

• The plan refuses to cover or pay for services the member believes should be covered.

• The plan or plan provider refuses to provide a service the member believes should be covered.

• The plan or plan provider reduces or cuts back on services or benefits the member has been receiving.

• The plan is stopping coverage of a service or benefit, and the member believes it is too soon to do so.

• The plan refuses to reimburse the member for drugs paid for out-ofpocket.

• The plan has miscalculated the member’s true out-of-pocket amount.

For more information, contact the Medicare Insurance Broker Sandra Teel at 657-2044224 (office) or 909-856-9379 (cell).