The Medicare complaints process allows beneficiaries to file complaints or grievances about the quality of the services they receive from Medicare Advantage (MA) and Part D prescription drug plans and their providers. It is distinct from the appeals process, which is intended to dispute denials and challenge costs of care. The complaints 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 is working for beneficiaries. Beneficiaries who need help filing complaints can get assistance through 1-800-MEDICARE or their local State Health Insurance Assistance Program (SHIP), a Medicare consumer support program funded by federal grants. However, few beneficiaries file complaints, and advocates describe the process as complicated and obscure, which deters rather than encourages its effective use.
To explore how the Medicare complaints process is working, we held three roundtable discussions — one with SHIP staff, one with organizations that advocate for legislative and regulatory changes on behalf of Medicare beneficiaries (i.e., beneficiary advocates), and one with representatives from provider associations — to identify problems in the process and explore potential improvements. This blog post summarizes our high-level findings and recommendations. More detail is available in our accompanying report.
Complaints Process Is Difficult to Navigate
Beneficiary advocates reported that filing a complaint about a Medicare health plan or provider requires knowledge about health insurance coverage that Medicare beneficiaries typically lack, including identifying the specific plan or coverage responsible for their problem (e.g., Part D, MA plan, or Medicaid, for those enrolled) and understanding the process for reporting the problem. Advocates also emphasized that filing complaints requires significant time and persistence from beneficiaries and is particularly challenging for people with serious illnesses.
SHIP staff and other consumer assisters also reported difficulties helping beneficiaries file complaints. SHIP staff said they lack sufficient access to CMS data systems to help them verify beneficiaries’ enrollment history and file complaints directly on their behalf. SHIP staff and other assisters also said they feel they have to word complaints precisely, sometimes including a direct reference to the regulation violated, to get attention.
CMS Processes for Resolving Complaints and Holding Plans Accountable Are Unclear
SHIP staff and other assisters said it is unclear how complaints progress within CMS and how complaints are resolved. CMS assigns each SHIP a point of contact within the agency. However, assisters said that they do not receive any information about complaint resolution unless beneficiaries provide it directly. Because most assisters also lack access to CMS’s complaints tracking module, the data system for tracking and resolving complaints, they said it is difficult for them to help beneficiaries follow up on the status of a complaint or to dispute a complaint resolution.
Beneficiary advocates and SHIPs also lacked information on how CMS uses complaints data to inform oversight, enforcement, and policymaking. SHIP staff said they do not receive data about common complaints in their state or local area and have no sense of complaint patterns or recurring issues.
Medicare Consumer Assistance Programs Are Underfunded
Both beneficiary advocates and SHIP staff noted that many complaints arise from aggressive or deceptive marketing and enrollment practices in MA by plans and their representatives. Neutral third-party enrollment and coverage assistance through SHIPs can help combat misinformation, but SHIPs are underfunded: they received about $70 million in grants in 2023 to serve more than 65 million Medicare beneficiaries.
Improving and Expanding the Medicare Complaints Process
Based on these findings, CMS could pursue several approaches to enhancing consumer assistance in Medicare.
- Reducing barriers to beneficiaries’ ability to file complaints by enhancing education and outreach on how to seek relief, clearly stating any documentation requirements and timelines for follow-up, and improving transparency about how the complaints process works.
- Improving read-only access to CMS data systems for SHIPs while maintaining appropriate protection for sensitive information. Establish aggregate data reporting to SHIPs about complaints in their state and appropriate resolutions to help them better understand the context for complaints and potential solutions for beneficiaries.
- Enhancing transparency and accountability by making complaints data public by insurer and type of complaint and letting the public know how CMS is holding plans and providers accountable. CMS also should consider creating a feedback process for beneficiaries and assisters to assess whether complaint “resolutions” actually addressed their concerns.
- Continuing to refine oversight and rulemaking to address abuses identified via complaints. CMS has recently implemented regulatory changes to reduce marketing abuses and simplify prior-authorization processes. Continuing this work will help beneficiaries and their providers and may reduce the volume of complaints. Further, CMS should consider developing additional measures of administrative effectiveness for MA plans, including claims processing time, prior-authorization paperwork burdens, and detailed data on complaints and grievances by type.
- Explore creation of a provider complaints option to allow providers to identify systemic issues or ones that affect multiple beneficiaries, potentially including a web-based complaint form.
- Work with Congress to enhance funding for Medicare consumer assistance. Underfunding of neutral consumer assistance leads to confusion, difficulty filing complaints and appeals, and inequities in accessing help. Congress should consider appropriating additional funds for Medicare consumer assistance to support enrollment assistance and resolve appeals, complaints, and grievances.
