The Medicare program serves 67 million beneficiaries; most receive at least some of their benefits through private plans. The Medicare complaints process allows beneficiaries to file complaints or grievances about the quality of the services they receive from Medicare plans, including issues with enrollment, customer service, or the ability to use their benefits. The US Department of Health and Human Services also funds State Health Insurance Assistance Programs (SHIPs) to provide in-person and telephone support to beneficiaries in their local area who need help enrolling in or using their Medicare coverage, including filing complaints.

The Medicare complaint process serves two important purposes: to give beneficiaries an outlet to address problems they face with Medicare plans and providers and to provide the Centers for Medicare and Medicaid Services (CMS) with insight into how the Medicare program works for the beneficiaries who use it. Problems in the Medicare complaints process can lead beneficiaries to abandon complaints and leave CMS with incomplete data to oversee the Medicare program. To explore how the Medicare complaints process works, we held three roundtables with SHIP staff, beneficiary advocates, and provider associations to identify issues and opportunities in the Medicare complaints process and possible paths for improvement.

Overall, the SHIP staff, beneficiary advocates, and provider association representatives who participated in our roundtables described the Medicare complaints process as obscure and complicated, deterring rather than encouraging its effective use. Our roundtable participants identified three primary groups of issues with the Medicare complaints process:

1. Many beneficiaries, SHIPs, and other assisters have difficulty navigating the Medicare complaint process through to resolution. Beneficiary advocates also emphasized that filing complaints requires extraordinary time and persistence from the beneficiary and is particularly challenging for people with serious illnesses.
2. SHIP staff, beneficiary advocates, and provider association representatives were all unclear on CMS processes for resolving complaints, how complaint data is used internally, and how CMS uses complaints to hold Medicare plans accountable.
3. Roundtable attendees noted that Medicare consumer assistance programs lack sufficient resources to effectively help beneficiaries navigate complex enrollment, appeal, and complaint processes without adequate assistance.

Suggested Approaches to Improve and Expand the Medicare Complaints Process

Based on our roundtable discussions, we encourage CMS to pursue the following approaches to improving the Medicare complaints process:

• Reduce beneficiary barriers to filing complaints.
  • Enhance beneficiary education and outreach about how to file complaints and grievances.
  • Improve transparency for beneficiaries, SHIPs, and other stakeholders about how the complaint process works within CMS, including any documentation requirements and timelines for follow-up.
  • Encourage states to pool assistance program funding into an all-payer consumer assistance program (like in New York).
• Reduce barriers to complaint assistance.
  • Improve SHIPs’ read-only access to CMS data systems while maintaining appropriate protections for sensitive information.
  • Establish aggregate data reporting to SHIPs describing complaints in their state and resolutions to those complaints to help assisters better understand the context for complaints and the potential solutions available to beneficiaries.
• Improve transparency and accountability.
  • Improve transparency about how CMS's complaint process works and how CMS holds providers and plans accountable.
  • Implement a feedback process for beneficiaries and assisters to assess whether complaint resolutions addressed their concerns.
  • Make complaints data publicly available by insurer and type of complaint.
• Continue refining oversight and rulemaking to address abuses identified via complaints.
  • Further, consider adopting and publicly reporting additional measures of administrative effectiveness for MA plans, including claims processing time, measures of prior authorization paperwork burdens, and more detailed data on complaints and grievances by type.
• Consider establishing an online complaint form for providers to identify systemic issues that may be occurring across multiple beneficiaries. A web-based form would allow providers to flag issues they and their patients face with MA and Part D plans for CMS oversight.

Finally, we further encourage Congress to appropriate additional funds for consumer assistance in Medicare to support enrollment assistance and help resolve complaints and grievances.