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Medicaid Fair Hearings in NYS - Common Links and Changes

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Posted: 10 Jan, 2023
by Valerie Bogart (New York Legal Assistance Group)
Updated: 04 Oct, 2023
by Valerie Bogart (New York Legal Assistance Group)

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 an exhaustive article about fair hearings.  See information here about TELEPHONE HEARINGS, which became the main method of holding hearings during the COVID pandemic.  THis was a big change from the priof model of holding in-person hearings UNLESS an individual was "homebound," and then a telephone hearing could be held.    

In this article:

  1. Key Links and Websites

  2. NEW PRO SE RESOURCE Fair Hearing Help NY website 

  3. Medicaid Advantage Plus (MAP) or "FIDE"  Hearings -- WARNING  

  4. OTDA Telephone Hearings - Changes Since 2020

1. Key Links and Websites

2.  NEW PRO SE RESOURCE:  Fair Hearing Help NY website 

http://fairhearinghelpny.org/ - Developed in collaboration with the Lawyering in the Digital Age Clinic at Columbia Law School, Empire Justice Center, The Legal Aid Society, and New York Legal Assistance Group, FairhearinghelpNY.org offers self-represented people information that will allow them to more fully participate in their Fair Hearting and exercise their due process rightsEmphasis is on public benefits, not Medicaid. 

Medicaid Advantage Plus (MAP) or "FIDE"  Hearings -- WARNING -  

The NYS OTDA Fair Hearing website above cannot be used for Medicaid Advantage Plus (MAP) plans, also called FIDE plans (Fully integrated Dual Eligible).  These hearings are operated under a unique "integrated" hearing system, which covers both Medicaid and Medicare denials by MAP plans.  Those plans use different notices.  The big difference is that the member does not have to request a fair hearing!  The plan is required to  AUTOMATICALLY forward all adverse decisions after a plan appeal for a hearing to be scheduled.  See more about MAP FIDE hearings here. 

  • Check to see which type of MLTC plan your client is in - regular MLTC or a MAP.  Now that nearly 38,000 people are in MAP plans, it's important to check.  Just knowing the name of the insurance company doesn't help, since companies operate both a regular MLTC plan and a MAP plan.  Ask the client for their membership ID or a notice with the official name of the plan, and then check in a few places:

    1. See plan lists for "long term care" plans on the NY Medicaid Choice website, (Scroll down to long term care plans for your region), 

    2. See NYS DOH MLTC Plan Directory ("Partial" = "regular" MLTC) 

    3. NY Medicaid Choice site - at the bottom of the home page click on  Sitemap -→ Main Menu → Enroll → Check My Case - complete the form - need consumer's date of birth and NYS Benefit ID number or case number.

  • MAP:  OTDA Integrated Appeal Hearing Office (IAHO)   1 (844) 523-8777

4.  OTDA TELEPHONE HEARINGS - Changes Since March 2020

Webpage -  https://otda.ny.gov/hearings/telephonic-hearings.asp   

  • Before the COVID pandemic,  telephone hearings were only available to people determined to be "homebound," meaning that because of mental or physical disabilities, they cannot travel to a fair hearing without substantial hardship or medical detriment.  This is under the Varshavsky class action injunction. See more about Varshavsky  procedures in this article.  Under Varshavsky, if a "homebound" person lost the telephone hearing, OTDA could only issue an hearing decision that was wholly favorable for the appellant.  Otherwise, OTDA must schedule a second part of the hearing in the appellant's home.  Meanwhile, the appellant may be entitled to an increase in hours pending that home hearing.  See more in the Varshavsky article.  

  • A telephone hearing demonstration program in which virtually all hearings are held by telephone was launched in  March 2020.  This demonstration was most recently extended through March 12, 2024 in  23-01 Continuing Demonstration Project on Allowing or Requiring Fair Hearing Appearances by Written, Telephonic, Video, or Other Electronic Means (Mar. 10, 2023)

  • See previous extensions of this demonstration here.  Under the demo, all hearings are held by phone, video "or other means,"  unless the appellant requests the hearing to be held in-person, or the ALJ or OTDA finds an in-person hearing should be held. 

  • FAQ - April 16, 2020 -  OTDA OAH Transittal 2020-03 - Frequently Asked Questions about Phone Hearings 

  • How to Submit Evidence at Phone Hearing - see Telephone Hearing website  

  • WHEN - must submit documents TWO BUSINESS DAYS before FH 

  • Local districts or Managed care plans must provide documents they plan to submit to the Appellant and their rep to be received at least one day in advance. 

  • How Hearing is conducted -- Please see the 23-01 Continuing Demonstration Project on Allowing or Requiring Fair Hearing Appearances by Written, Telephonic, Video, or Other Electronic Means  for detailed information on how the phone hearing is conducted  - how the Caller ID number may appear, three-way calls, etc.  Here are just a few excerpts from this directive:

    • "Hearing Officers will contact the parties at the provided phone numbers. If there is no answer, Hearing Officers will try to leave voice messages. Hearing Officers will call Appellants and their authorized representatives two times with at least ten minutes between calls. If the Appellant and their authorized representative fails to answer, OAH may deem the request for a fair hearing abandoned in accordance with 18 NYCRR § 358-5.5. OAH will attempt to advise Agencies if hearing requests are withdrawn prior to the hearing date or if the Appellant or Appellant’s representative fails to participate in the hearing."  23-01 Directive at  p. 5

    • "Hearing Officers will conference all participants into the telephonic hearing and may permit parties to add others to develop a complete record. All parties will be identified. The audio component of hearings will be recorded. Only OAH may record the fair hearing (see, 18 NYCRR § 358-5.11). Hearing Officers will generally inquire whether the Appellant and their authorized representative received a copy of the Agency’s evidence and if the Appellant submitted evidence."   23-01 directive at p. 

  • ADVOCACY:    Letter to OTDA 3/24/20 Requesting Clarification of GIS above and for protections for appellants in the new phone hearing procedures - from NYLAG, Legal Aid Society, Empire Justice Center & other organizations.

  • Phone Contact to OTDA re Scheduling, Adjournments, Etc.
    • MAP:  IAHO           1 (844) 523-8777
    • MLTC: OTDA OAH 1 (800) 342-3334

 NYS OTDA - Previous Directives about the Telephone Hearing Demonstration:     

  1.  Office of Administrative Hearings Transmittal 20-02; 20 TA/DC014 – Hearings by Phone (3/12/2020)  Initial demonstration is from March 12 to Sept. 12, 2020 

  2. FAQ - April 16, 2020 -  OTDA OAH Transittal 2020-03 - Frequently Asked Questions about Phone Hearings 

  3. GIS 20 TA/DC-076:  “Allowing or Requiring Fair Hearing Appearances by Written, Telephonic, Video, or Other Electronic Means"  (July 17, 2020) (EXTENDED TO March 12, 2021)

  4. 20 GIS TA/DC 097 – NYS OTDA Office of Admin. Hearings (OAH) Transmittal 20-05 - Allowing or Requiring Fair Hearing Appearances by Written, Telephonic, Video, or other Electronic Means - (10/16/20) continues  through March 12, 2021, 

  5. 21 TA/DC 013 – OAH Transmittal 21-1 - Demonstration Project Conducting Hearings by Telephone Video and Other Means of Communication (3/15/2021) - continues through March 12, 2022."

  6.  22TA/DC024 — Demonstration Project — Conducting Hearings by Telephone, Video, and Other Means of Communication (03/11/22)

For more information

Legal Services NYC Video Series on Fair Hearings 


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Also read
item Appeals & Grievances in Managed Long Term Care - "Exhaustion" of Plan Appeal Required since 2018
item Medicaid Advantage Plus "MAP" - New "FIDE" Appeals & Hearing Process began 2020 - Healthfirst Mistake March 2021
item Right to a "Home Hearing" under Varshavsky Case - Special Rights in Fair Hearings Seeking Increases in Medicaid Home Care
item Requesting a New or Increased Service from a Medicaid Managed Care or MLTC
item Getting Help with Managed Long Term Care

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Medical Records Must be Provided FREE if Needed to Support...       What You Need to Know About Medicaid and Fair Hearings


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