Funder: The Commonwealth Fund and The SCAN Foundation

Author: Alexandra Kruse and Ann Mary Philip, Center for Health Care Strategies

January 2015 | Technical Assistance Brief


A user-friendly appeals process that gives people an easy way to request reconsideration of coverage or payment decisions is critical to the success of person-centered, integrated care programs. Misalignments between Medicare and Medicaid appeals processes, however, pose barriers for states seeking to integrate these mechanisms in new models of care.

This brief, made possible through support from The Commonwealth Fund and The SCAN Foundation, explores opportunities for states to develop an integrated appeals process, whether through a Dual Eligible Special Needs Plan (D-SNP) or a financial alignment demonstration. It presents lessons from Minnesota’s D-SNP based Senior Health Options program and the Health Plan of San Mateo on aligning appeals processes, coverage determinations, and provider payments at the health plan level. It also highlights a significant opportunity for states implementing financial alignment demonstrations to develop fully integrated appeals processes including early insights from New York’s Fully Integrated Duals Advantage program.