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Coming July 1st: MLTC Members May Request Fair Hearing Without first Requesting Internal Appeal from Plan ("Exhaustion" Requirement ELIMINATED)

11 Jun, 2015

Managed Long Term Care Appeals System Change

Exhaustion Requirement to be Eliminated Effective July 1, 2015

Since early June 2015, everyone in Managed Long Term Care (MLTC) plans have been receiving a notice from their MLTC plan that looks like this sample notice.   This notice has caused a lot of confusion.   The notice is about a change in the appeals process generally. It is not a notice that any individual member's services are being reduced.  Here is information about the change.  More about the Grievance and Appeals process in MLTC is posted in this article.

Until now, consumers whose home care hours were reduced by their MLTC plan had to request an "internal appeal" by the plan to reconsider its decision before requesting a fair hearing against the plan.   The New York State Department of Health announced by webinar on April 29, 2015 that this requirement would be eliminated on July 1, 2015.  The webinar and accompanying slides are available on the MRT 90 website under "Partial Capitation Model Action Notices."

MLTC Plans are tasked with notifying their enrollees about this change.  DOH required plans to send this model notice on plan letterhead to all enrollees in early June 2015 in order to alert them to this change and the consequences that flow from this change.  The notice is discussed at slides 11 and 12 of the webinar.  Plans are encouraged to not rely solely on this notice when educating enrollees about this change. 

The changes effective July 1, 2015 are as follows:

  • MLTC members can request a fair hearing without having first exhausted internal appeals by the MLTC plan,

  • MLTC members may still request an internal appeal by their MLTC plan before requesting a state fair hearing, BUT

  • MLTC members will only get aid continuing if they

    • Request a fair hearing with aid continuing, and

    • Make the hearing request before the effective date of the plan's threatened reduction of services, or within 10 days of the notice date, whichever is later

  • The deadline to request a fair hearing is 60 calendar days after the mailing of an adverse notice, or the effective date of the adverse notice, whichever is later.   But - they will only get AID CONTINUING if they request the hearing within the first 10 days or before the effective date.

MLTC members can still request an internal appeal instead of, or concurrently with, a fair hearing, BUT NOTE:

  • MLTC members will NOT get aid continuing if they ONLY request an internal appeal
  • The deadline to request an internal appeal is now 60 business days after the mailing of an adverse notice, or the effective date of the adverse notice, whichever is later (instead of 45 days; this brings the MLTC internal appeal process in-line with the internal appeal process in Mainstream Managed Care plans)

Plans must send notices of any reduction or termination of services at least 10 days before the effective date of the change.

For more on appeals see this article.

New Model Notices Effective for Actions Starting July 1, 2015 (MLTC Plans ONLY - not FIDA)

DOH announced in the same webinar that, starting July 1, 2015, plans must use two new model notices when making any decisions that are adverse to the consumer.  Both of the 2 notices described below, along with DOH samples of how the templates are used, are posted in this PDF, along with the March 2015 State directive to plans enclosing the notices.

  • Model Initial Adverse Determination (IAD)(pp 12 -22 of this PDF)
    • Replaces the Plan Decision Template found in Appendix K of the Model Contract
    • Provides details on all three appeals options (internal, external, and fair hearing)
  • 4687 MLTC Action Taken - Denial, Reduction or Termination of Benefits ("Action Taken Notice") (pp 4-11 of this PDF)
    • Informs consumers of their fair hearing rights regarding the action
    • Provides consumers with a form they can submit to request a fair hearing

Plans are responsible for translating the notices into prevalent languages  (See Q. 11 in accompanying FAQ on MRT 90 website).

Adverse determinations triggering these notices continue to include most actions defined in Appendix J of the Model Contract:

  • Denials of services requested by the consumer
  • Limited authorizations of services requested by the consumer
  • Terminations of services previously authorized
  • Denials of payment for services (usually for services already rendered)
  • Determinations that a service or benefit is not covered

The following actions DO NOT require use of the new model notices, but may in the future:

  • Failure to provide services in a timely manner
  • Failure to make a grievance or grievance appeal determination in the time frame required by the model contract

Note: these new notices are for Partially Capitated Plans only, which means MLTC plans, not Medicaid Advantage Plus or PACE plans.  FIDA notices are different as well.


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