December 2019: Complaints and Grievances

What is a Grievance?

A grievance is a formal complaint that you file with your plan. If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance.

A grievance is not an appeal, which is a request for your plan to cover a service or item that it has denied. Times when you may wish to file a grievance include if your plan has poor customer service or you face administrative problems.

Some examples of issues that might lead you to file a grievance include:

  • Your plan fails to return a coverage determination or appeal decision on time
  • Your plan fails to expedite a coverage determination or appeal
  • You experience poor quality of care from an in-network provider
  • You experience poor customer service from a plan representative
  • You are asked to pay an incorrect copayment amount
  • You are involuntarily disenrolled from your plan
  • There is a change in premiums or cost-sharing
  • You receive inadequate written communications from your plan
  • You experience marketing abuse

In some cases, you may want to file both an appeal and a grievance.

To file a grievance, send a letter to your plan’s Grievance and Appeals department. Visit your plan’s website or contact them by phone for the address. You can also file a grievance with your plan over the phone, but it is recommended to send your complaints in writing. Be sure to send your grievance to your plan within 60 days of the event that led to the grievance.

Your plan must investigate your grievance and get back to you within 30 days. If you made your grievance in writing, the plan must respond to you in writing. If you make your request over the phone, your plan may respond verbally or in writing, unless you specifically request that the response be in writing. If your request is urgent, your plan must get back to you within 24 hours. If you have not heard back from your plan within this time, you can check the status of your grievance by calling your plan.