Plain-language definition
A grievance is a complaint about a Medicare Advantage plan, another Medicare health plan, or a Part D plan. It can concern customer service, appointment access, staff behavior, confusing materials, quality of care, or the way a plan handled a determination or appeal. It is not the route for deciding whether the plan should cover or pay for a benefit.
Practical example
A Part D plan denies a request for an expedited coverage determination and the person has not received the disputed drug. The coverage issue follows the appeal route. The refusal to use the expedited process can also support an expedited grievance that the plan must address within 24 hours.
How it differs from related terms
- Organization determination: a Medicare Advantage plan’s initial coverage, authorization, provision, or payment decision.
- Coverage determination: a Part D plan’s initial decision about a prescription drug or exception.
- Appeal: a request to review and change an unfavorable coverage or payment decision.
- Quality-of-care complaint: a type of grievance that may also be submitted to the BFCC-QIO serving the enrollee’s state.
- Inquiry: a request for information that does not necessarily express dissatisfaction or ask the plan to investigate a complaint.
Administrative context
CMS requires Medicare Advantage and Part D plans to maintain meaningful grievance procedures. Grievances may generally be submitted orally or in writing within 60 calendar days of the incident. Standard grievances are resolved as quickly as health requires and generally within 30 calendar days, subject to a permitted extension of up to 14 days in the enrollee’s interest.
Official sources
- CMS — Medicare managed care grievances
- CMS — Medicare Part D grievances
- Medicare.gov — filing a complaint
- eCFR — 42 CFR 422.564
- eCFR — 42 CFR 423.564