Question 1

What's the difference between a grievance and an appeal?

Accepted Answer

A grievance is a complaint about service delivery or quality of care, regardless of whether you want anything changed as a result — resolved within 30 days, with a right to also file a quality-of-care complaint with the QIO. An appeal is specifically about a service determination — a denial, reduction, or termination of a service — with its own real deadlines and levels of review.

Question 2

Does the PACE organization have to see my parent in person before reducing a service?

Accepted Answer

Yes, if it expects to deny or partially deny the request — an in-person reassessment by the appropriate team members is required first, evaluating whether the service is still necessary for your parent's medical, physical, emotional, and social needs.

Question 3

Can services keep going while we appeal?

Accepted Answer

Every required service continues for everyone during a grievance or an appeal. A Medicaid participant has an additional right: if the PACE organization is reducing or stopping a service you're already getting, you can ask to keep that specific service going too, understanding you may be liable for its cost if the final decision goes against you.

Question 4

My parent has both Medicare and Medicaid — which external review do we use?

Accepted Answer

A dual-eligible participant can choose either the Independent Review Entity (the Medicare path) or a state fair hearing (the Medicaid path) — but only one, not both.

Question 5

What does Appeals Plus cost for a PACE case?

Accepted Answer

$39, one time, per case — covering every appeal level for 12 months, including any later letter the case needs as it advances.

Your parent's PACE organization wants to reduce or stop a service. Here's what to do.