Accountable Care Collaborative Medicare-Medicaid Program Feedback Form

The Department would like to hear your thoughts about the Accountable Care Collaborative: Medicare-Medicaid Program (ACC: MMP). Please tell us about your experience with the program, good or bad, so we can learn how the program is working and find ways to make it better.

Please use this form to tell us about any good experiences or problems you have with the ACC: MMP. Please also share any questions you have about the program so we can answer them for you.

If you have an immediate concern, your Regional Care Collaborative Organization (RCCO) may be able to help.  Below is a list of RCCOs. Please contact the RCCO in your county to get help.

If you have a concern or feedback that your RCCO cannot help you with or that you would like to share directly with the State Medicaid Department, please fill out the information below.

 

Part 1: About You

This will help us follow up and solve the problem.

Only items with *are required.

Part 2: About the ACC client

(Skip if same as above)

Part 3: Reason filling out form*

(Check all that apply)

Part 4: Comments

Please note:

  • This page is secure to protect your personal health information.
  • Completing this form will not hurt your enrollment status or benefits.
  • In order to help you with your concern and improve our program, we may need to share information on this form with Department staff and/or the Medicare-Medicaid Ombudsman. The Ombudsman is an independent person that can help you resolve problems you may be having with your Medicare or Medicaid providers or benefits.
  • If we suspect abuse, the Department must contact the appropriate authorities.
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