2025 Medicaid Fair Hearing Compliance Plan

In New York, there are over 10,000 Medicaid fair hearings pending past the 90-day deadline. The backlog grew significantly during the COVID-19 Public Health Emergency and is the largest in the nation. To address the backlog and avoid corrective action, the Department of Health (DOH) announced a fair hearing compliance agreement on February 4, 2025.  The compliance plan is in effect through December 31, 2025.     

This policy was announced as MLTC Policy 25.01 and in a February 4, 2025 Letter to Managed Care Plans.  The Feb 4. letter is attached to the article. 

The Pre-Hearing Disposition (PHD) Process

The main strategy of New York's fair hearing compliance plan is a pre-hearing disposition (PHD) process. A PHD has the same impact as a fully favorable fair hearing decision for the Appellant. This means that if a PHD is issued, the fair hearing should be fully resolved in the Appellant's favor avoiding the need for the hearing. An example of a PHD is attached to this article.  
 

Under the compliance plan, DOH has directed Medicaid Managed Care Plans (MMCP) to attest to a PHD for certain pending fair hearings. DOH has identified pending hearings with the following criteria as eligible for a PHD.  The pending hearings must be:

• Over 1 year old
• Just one issue for the hearing
• Appellant has aid continuing or Varshavsky interim relief (including home hearings)
• Involve discontinuances, reductions, or inadequacy

In February 2025, DOH sent each MMCP a spreadsheet of pending hearings and required the MMCP to attest to a PHD for each matter. MMCP's responded to the first batch of pending hearings in mid-February 2025. PHDs are expected to be issued the week of March 3, 2025.

After a PHD is issued by the Office of Temporary Disability Administration (OTDA) the MMCP must issue a new service authorization to the member. The service authorization must specify the type and amount of services as required by the Aid Continuing (AC) order.

DOH intends to send additional batches of pending hearings to MMCPs to be reviewed for PHDs throughout the year. 
 

Consumer Protections After the PHD 

Following a PHD, an MMCP may not take action to reduce or discontinue hours of service without conducting a new assessment, which must occur after the date the PHD is issued.  If the MMCP seeks to reduce or discontinue care after the new assessment, the MMCP must comply with all procedures including providing timely and advance notice complying with MLTC 16.06.