The Medicaid and Chip Payment and Access Commission (MACPAC) voted in favor of seven recommendations during a meeting Jan. 26 that would reshape how beneficiaries are able to appeal for care.
Out of the seven votes, only the first vote did not receive unanimous approval to recommend approval to Congress, as it passed 13-3, with one member abstaining. That recommendation called for amending the Social Security Act to "require that states establish an independent, external medical review process."
A review would be completed by a clinician, not an administrative law judge. More than a dozen states already have an external medical review for Medicaid members, resulting in a fully or partially overturned ruling 46% of the time, the body found. The Congressional Budget Office said direct spending would increase less than $500 million over 10 years.
MACPAC agreed that Centers for Medicare & Medicaid Services (CMS) should give more information to beneficiaries about why a claim was denied and that managed care organizations should help beneficiaries navigate the appeals journey. The commission also called for giving the option to receive an electronic denial notice instead of having to wait for a mailed notice.
Additionally, the March report to Congress will include a recommendation to extend the timeline for requesting continuation of benefits, as extending the 10-day window could increase access to care.
Currently, MCOs have an internal system to review appeals by beneficiaries that feel they have a right to be covered. But beneficiaries feel the process is slow, difficult and confusing, and no federal rules exist requiring states to collect or report data on denials and appeals.
MACPAC now urges CMS to change data collection and reporting requirements to better monitor the performance of the managed care program. Annual reports would also be posted to the CMS website. It also calls on Congress to conduct routine audits, another recommendation that would increase spending by less than $500 million over a 10-year period.
Prior authorization denials have been more commonplace by Medicaid MCOs than Medicare Advantage organizations, according to a 2023 Department of Health and Human Services Office of Inspector General report about 2019 data.