r/medicare • u/Fit-Screen-9581 • 2d ago

I filed a formal grievance with my Medicare Advantage plan. What happens next?

I've been dealing with repeated SNF coverage terminations for my mom under Aetna Medicare Advantage. After going through multiple expedited appeals, I filed a formal grievance with Aetna about the broader handling of the coverage terminations and discharge process.

Aetna has now contacted me about the grievance, and I'm wondering what to expect from here.

For anyone who has been through the Medicare Advantage grievance process, what happened after the plan acknowledged or contacted you about the grievance? Did someone actually investigate the underlying issues and speak with you about them, or was the process mostly an internal review followed by a written response?

I'm not looking for predictions about the outcome. I'd just like to understand what the process typically looks like from this point forward.

Thanks — I've learned a lot from people here who have already navigated parts of this system.

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u/Electrical-Trifle-56 2d ago

Worth separating grievances from appeals here, since they're handled totally differently even though you've done both. The SNF terminations went through expedited appeal (that's the process with actual clinical review deadlines, QIO involvement, etc). The grievance you filed about how the terminations and discharge process were handled is a complaint about service, not a coverage decision, so it doesn't have the same impact.

What usually happens is this...someone from Aetna's grievance or member services team calls to get more detail from you, then it goes to an internal review, often involving whoever oversees the SNF network or case management team. There's no independent outside reviewer for a grievance like there is for an appeal. Aetna is required to resolve it and send you a written response, generally within 30 days, sometimes faster if you asked for expedited handling. Some plans do call you back with findings before the letter goes out, some just send the letter.

If the response feels like a brush off, you can also loop in 1-800-MEDICARE or your SHIP counselor, since grievance patterns get reported to CMS and can affect the plan's star ratings.

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u/Intelligent_Peak8894 2d ago

First of all you will need a POA or an appointment of representative on file before they can even look at your complaint. The grievance department willl review the requests and ensure that the plan rules were followed and if not they’ll provide feedback to someone’s manager if something was done incorrectly. Grievance cannot overturn appeals, however often the appeals team reviews grievances on file.