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Requesting a New or Increased Service from a Medicaid Managed Care or MLTC
Members of Medicaid Managed Care plans, including Managed Long Term Care (MLTC) plans, have the right to request a NEW service that was not previously authorized ("prior authorization"), or an INCREASE In a service they already have ("concurrent review"), such as more hours of personal care or...
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Right to a "Home Hearing" under Varshavsky Case - Special Rights in Fair Hearings Seeking Increases in Medicaid Home Care
RIGHTS of People Who Cannot Travel to a Fair Hearing Because of Disability This article can also be downloaded as a Fact Sheet here. Individuals who, because of mental or physical disabilities, cannot travel to a fair hearing without substantial hardship or medical detriment, have rights...
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Appeals & Grievances in Managed Long Term Care - "Exhaustion" of Plan Appeal Required since 2018
In 2016, CMS adopted changes in federal Medicaid managed care regulations requiring "exhaustion" of Plan Appeals prior to requesting a Fair Hearing. These changes became effective in NYS in MAY 2018. The federal changes are in 42 CFR 438 SubPart F. NYLAG 2018 Trainings on Changes: View the...
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Medicaid Advantage Plus "MAP" - New "FIDE" Appeals & Hearing Process began 2020 - Healthfirst Mistake March 2021
In 2020, a new "integrated" appeal and fair hearing process launched for about 10% of Managed Long Term Care members those who are in Medicaid Advantage Plus (“MAP”), which consists of a "FIDE-SNP" (Fully Integrated Dual Eligible - Special Needs Plan) that covers the Medicare services, and a...
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Getting Help with Managed Long Term Care
Here are organizations where you can seek help for problems with Medicaid Managed Long Term Care and Medicaid Advantage Plus. Also see these KNOW YOUR RIGHTS Fact Sheets about MLTC and related topics STATEWIDE ICAN – Independent Consumer Assistance Network – ...
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Grievance and Appeal Contacts for Managed Long Term Care Plans
SINCE MARCH 1, 2018, members of Medicaid Managed Care and Managed Long Term Care plans will be required to request an INTERNAL APPEAL within their plan, and wait until the plan decides that appeal before they may request a FAIR HEARING when they receive an Initial Adverse Determination denying or...
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Health Plan Appeal Rights in New York After the Affordable Care Act
Samuel Salganik, an attorney at Community Health Advocates of the Community Services Society (CSS) wrote this incredibly thorough article breaking down the types of appeal rights available to individuals covered by the various types of private health insurance plans in New York. This article...
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Medical Records Must be Provided FREE if Needed to Support Claims for Public Benefits - New September 2017
In September 2017, a new law went into effect that requires health care providers to provide medical records at no charge, when needed to support an application, claim or appeal for a government benefit or program. Here's what the law adds to Mental Hygiene Law § 331 and NYS Public Health Law §...
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Medicaid Fair Hearings in NYS - Common Links and Changes
Medicaid recipients have the right to request a Fair Hearing to appeal an adverse action. This includes decisions made by a managed care or Managed Long Term Care plan, by the local Dept. of Social Services, or by NYS's contractor, NY Medicaid Choice or the NY Independent Assessor. This is not...
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What You Need to Know About Medicaid and Fair Hearings
By the Legal Aid Society Medicaid is a comprehensive health insurance program for low-income people of all ages. Medicaid covers a variety of health services including home care, nursing home, dental, vision, crisis intervention, inpatient rehabilitation, outpatient services, opioid treatment...
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