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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: 21 Jan, 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.    

Key Links and Websites

  • Fair Hearing Resources webpage on the WNYLC Online Resource Center. - managed by Gene Doyle, has extensive information, reference lists, guidance, info on litigation, etc. 

  • NYS Office of Temporary & Disability Assistance  (OTDA) Fair Hearing Website - has forms to request, adjourn or withdraw fair hearing requests, or request FH online

  • Medicaid Advantage Plus (MAP) -- 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

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.  

  • In March 2020, OTDA launched a demonstration program in which virtually all hearings are held by telephone.  This demonstration has been extended several times, most recently through March 1, 2023 in  22TA/DC024 — Demonstration Project — Conducting Hearings by Telephone, Video, and Other Means of Communication (03/11/22).  See previous extensions 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

    • Upload - OTDA has unveiled a new process for Appellants and Representative to upload evidence for fair hearings using www.upload.ny.gov.   OAH Transmittal 9/1/2022 is not yet posted online.

    • E-Mail - may submit evidence by email to appdocs@otda.ny.gov   (since 8/2021) or 

    • FAX used for requesting fair hearings.. FAX 518-473-6735

    • MAP hearings - see article on MAP/FIDE hearings

  • WHEN - must submit documents TWO BUSINESS DAYS before FH 

  • 10/16/20 GIS 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 - continues Demonstration Phone Hearing program  through March 12, 2021, 

  • 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. 

    • "Agencies may request the waiver of their personal appearance at any hearing. OAH may draw a negative inference if an Agency representative is needed and not available to participate or contact information is not provided. Agencies planning to have a representative participate in the hearing should make specific reference thereto in the coversheet and summary. Failure to request contact specifically may result in a decision being issued based on documentary evidence alone.

    • "Hearing Officers will call Appellants and their authorized representatives two times during the scheduled hearing period, with at least twenty minutes between calls. If the Appellant and their authorized representative fails to answer, the hearing request may be considered abandoned."

  • 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 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."


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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