life or physical or mental health or ability to attain, maintain, or regain maximum function. § 438.414 Information about the grievance system to providers and subcontractors As discussed above, we are suggesting that grievance and appeal references in subpart F be clarified so that they are not confusing. RECOMMENDATION: Amend the regulation as follows: The MCO, PIHP, or PAHP must provide information specified in § 438.10(g)(2)(ix) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. § 438.416 Recordkeeping requirements. Health plans should be required to keep records on how well the process grievances and appeals. Poorly performing plans should improve under corrective action plans or be terminated from participating in Medicaid. RECOMMENDATION: Add a new subsection (d) to § 438.416 as follows: The State must also require the MCOs, PIHPs, and PAHPs to maintain records, on a quarterly basis, of the total number of grievances and of the total number of appeals, and for appeals: (i) the number of times the standard timeframe for resolution was extended, not at the request of the enrollee; (ii) the number of times the expedited timeframe for resolution was extended, not at the request of the enrollee, (iii) the number of timeframes specified in § 438.210(d) were not met. § 438.420 Continuation of benefits while the MCO, PAHPs, or PIHP appeal and the State fair hearing are pending. The National Health Law Program and advocates with whom we work nationwide thank CMS for promulgating this regulation. Consistent with the requirements for constitutional due process, this regulation is designed to allow an enrollee to maintain the previously authorized level of benefits uninterrupted pending the State fair hearing decision—including during the pendency of the plan level appeal. The preamble’s statement of intent is clear, as was CMS explanation of the regulation in employees’ webinar sponsored by CMS to explain the regulations. Nevertheless, this aspect of the grievance and appeals proposed regulations is, without question, has generated the
life or physical or mental health or ability to attain, maintain, or regain maximum function. § 438.414 Information about the grievance system to providers and subcontractors As discussed above, we are suggesting that grievance and appeal references in subpart F be clarified so that they are not confusing. RECOMMENDATION: Amend the regulation as follows: The MCO, PIHP, or PAHP must provide information specified in § 438.10(g)(2)(ix) about the grievance and appeal system to all providers and subcontractors at the time they enter into a contract. § 438.416 Recordkeeping requirements. Health plans should be required to keep records on how well the process grievances and appeals. Poorly performing plans should improve under corrective action plans or be terminated from participating in Medicaid. RECOMMENDATION: Add a new subsection (d) to § 438.416 as follows: The State must also require the MCOs, PIHPs, and PAHPs to maintain records, on a quarterly basis, of the total number of grievances and of the total number of appeals, and for appeals: (i) the number of times the standard timeframe for resolution was extended, not at the request of the enrollee; (ii) the number of times the expedited timeframe for resolution was extended, not at the request of the enrollee, (iii) the number of timeframes specified in § 438.210(d) were not met. § 438.420 Continuation of benefits while the MCO, PAHPs, or PIHP appeal and the State fair hearing are pending. The National Health Law Program and advocates with whom we work nationwide thank CMS for promulgating this regulation. Consistent with the requirements for constitutional due process, this regulation is designed to allow an enrollee to maintain the previously authorized level of benefits uninterrupted pending the State fair hearing decision—including during the pendency of the plan level appeal. The preamble’s statement of intent is clear, as was CMS employees’ explanation of the regulation in webinar sponsored by CMS to explain the regulations. Nevertheless, this aspect of the grievance and appeals proposed regulations is, without question, has generated the