CMS Pub. 100-16, ch. mc86c16b, § 20.2.10.1.1

The D-SNP must offer to provide the assistance described above and in 42 CFR 422.562(a)(5)(i)

whenever it becomes aware of an enrollee's need for a Medicaid-covered service. Offering such

assistance is not dependent on an enrollee's specific request. There are a number of ways in which a

D–SNP could become aware of the need for assistance. A non-exhaustive list includes: During a

health risk assessment when an enrollee shows a need for more LTSS than she currently receives

through Medicaid; during a request for coverage of a Medicaid-covered service made to the D–SNP;

and during a call to the D–SNP’ s customer service line.

Each D-SNP must offer to provide and actually provide assistance as required by 42 CFR

422.562(a)(5)(i) using multiple methods.

(A) When an enrollee accepts the offer of assistance described in 42 CFR 422.562(a)(5)(i), the

D-SNP may coach the enrollee on how to self-advocate.

(B) The D-SNP must also provide an enrollee reasonable assistance in completing forms and

taking procedural steps related to Medicaid grievances and appeals.

We expect that D–SNPs, as plans with expertise in serving dually eligible beneficiaries, should be

able to identify a potential Medicaid coverage issue as part of their regular assessments and care

management processes. For example, a D–SNP may become aware that an enrollee is unsatisfied

with the personal care services she is receiving based on the work of a care coordinator or from a

call or email from the enrollee or enrollee’ s family. We note that regulation text at 42 CFR

422.562(a)(5) does not explicitly require a D–SNP to use its care coordination or case management

programs to identify this type of issue.

Not all enrollees would need assistance in the actual filing of grievances and appeals; for many

enrollees, simply receiving information under 42 CFR 422.562(a)(5)(i) would be sufficient. However,

it would not be acceptable for a D–SNP to tell an enrollee simply to contact ‘‘Medicaid’’ in general

when the enrollee encounters a problem with his or her Medicaid coverage or is obviously in need of

assistance in figuring out how to file an appeal of a denial of Medicaid-covered benefits.