Filing a Grievance Example (PDF, 67KB, 1pg.)

Was your experience with your FIDA plan's provider not satisfactory? Did you have to wait too long to see the doctor or was the office staff not courteous?

You can "file a grievance" (make a formal complaint) with your FIDA plan. Remember, it is okay to complain to your FIDA plan about these and other service problems! Your plan wants to hear from you so that it can serve you better.

If you had a problem, you have 60 calendar days to file a grievance about it. Here is how you can do it:

1. Call your plan or your care manager.
2. Your plan will call or mail you its decision.
3. Call: Participant Ombudsman. The Ombudsman is known as the "Independent Consumer Advocacy Network," or "ICAN." ICAN will provide you with free assistance in accessing care, understanding and exercising your rights and responsibilities, filing grievances, and appealing adverse decisions. You can call ICAN at 1-844-614-8800 or Medicare at 1-800-633-4227.

How Soon Will My FIDA Plan Review My Grievance (Complaint)?

Usually, your plan will respond to your grievance within 30 days. However, there may be situations when your plan will respond to your grievance faster.

Your Plan Will Respond Within 30 Days If:

• Your grievance is about issues like poor customer service and there is no harm to your health. For example, the office staff was not courteous or your wait to see the doctor was too long.

Your Plan Will Respond Faster If:

• Your grievance is about your plan saying "No" to your request for an expedited appeal. You will get a response within 24 hours.
• Your plan did not decide on your appeal or grievance within the required length of time. You will get a response within 24 hours.
• Your grievance is about something that causes harm to your health. For example, your plan got your medication wrong or care staff did not turn you over enough to prevent bedsores. You will get a response within seven days.

Filing an Appeal Example (PDF, 11KB, 1pg.)

Your FIDA care team (IDT) uses its expert knowledge to make the best care plan for you. But you don't always have to agree.

If you ever disagree, you have the right to "appeal the decision." In other words, you can formally tell your plan that you disagree with its decision and that you want it looked at again. Here is how you can appeal a decision:

FIDA Appeals Steps 1 to 4

Example:

Your home attendant used to come to your place for 10 hours a week. Then your FIDA plan said six hours a week is enough. You disagree with this. What can you do? Appeal their decision.

You can take four steps to try to change your FIDA plan's decision. Click on each step to learn more about the process.

1. Appeal to your FIDA plan
2. Appeal to Integrated Administrative Hearings Office (IAHO)
3. Appeal to Medicare Appeal Council (MAC)
4. Appeal to Federal District Court

∗If you want to appeal decisions about medicines covered by Medicare Part D, please call the Participant Ombudsman at the Independent Consumer Advocacy Network (ICAN) or Medicare at 1-800-633-4227.

FIDA Appeals Step 1: File an appeal with your plan

Example:

Your home attendant used to provide 10 hours of care a week. Then your FIDA plan said six hours a week is enough.

If you appeal within 10 days of the plan's decision, you'll have your home attendant for 10 hours a week during step 1 and 2 of the appeals process. If you appeal within 60 days, you'll have your home attendant for only six hours during the appeals process.

1. Appeal: Call or write your plan
   1. If your plan rejects your appeal
      1. Home attendant for only six hours a week.
      2. Your appeal automatically goes to IAHO. See step 2
   2. If your plan agrees
      1. Home attendant for 10 hours a week

If your FIDA plan made a decision about the services you get and you do not like it, you have 60 days to appeal it. If you miss this deadline and have a good reason for missing it, you may be able to get more time to make your appeal.

• To keep getting your service(s) while the appeal is going on, you must appeal within 10 days of the FIDA plan's decision.
• To appeal, you can ask your FIDA plan to talk with its representative in person OR you can send a letter to your FIDA plan by regular or expedited mail.
• You should expect an answer from your FIDA plan within:
  • 72 hours* if you asked for a fast appeal (For more information, see Section 5.2, Chapter 9 of the Participant Handbook).
  • Seven calendar days* if your appeal is about Medicaid prescription drugs.
  • 60 calendar days* if you appeal your FIDA plan's decision not to pay you back for services for which you had to pay on your own.
  • 30 calendar days* for all other appeals.
  • *From the day your FIDA plan received the appeal.

FIDA Appeals Step 2: Integrated Administrative Hearings Office

If your FIDA plan did not decide in your favor, it will send your appeal to the Integrated Administrative Hearings Office (IAHO).

If you appealed your FIDA plan's decision within 10 days (see step 1), you will keep getting your service(s) until the IAHO makes a decision.

Example:

In step 1, your plan rejected your appeal to keep your home attendant for 10 hours a week. Because your plan said 'No' to your appeal, they will have to send it to the IAHO to look at it again. When your plan gets to step 2, you will get a letter from IAHO.

Remember, you will have your home attendant for 10 hours a week during the appeals process if in step 1 you appealed within 10 days of the plan's decision. If you appealed within 60 days, then you will have your home attendant for only six hours a week during the appeals process.

1. Appeal: Your plan automatically sends it to IAHO
   1. If IAHO rejects your appeal
      1. Home attendant for only six hours a week
      2. You can Appeal to Medicare Appeal Council (MAC).
   2. If IAHO agrees
      1. Home attendant for 10 hours a week

• You can ask the IAHO staff for a hearing over the phone or in person.
• If your appeal is about Medicaid prescription drugs, the IAHO must give you an answer within seven calendar days after it gets your appeal.
• For all other appeals, the IAHO must give you an answer within 90 calendar days from the date you asked for an appeal with your FIDA plan.
• However, if you originally had a fast appeal in step 1, you will automatically have a fast appeal in step 2. In this case, the IAHO will give you an answer within 72 hours of when it gets your appeal.

If you disagree with the IAHO decision and have questions about what other steps you can take, call the Independent Consumer Advocacy Network (ICAN) at 1-844-614-8800.

Step 3: Appeal to Medicare Appeals Council (MAC)

Call ICAN for information on how to file an appeal with the MAC

Step 4: Appeal to Federal District Court

Call ICAN for information on how to file an appeal with the Federal District Court