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Medicaid Managed Care
Medicaid Recipients to be "Default Enrolled" into Medicare Special Needs Plans when they Enroll in Medicare-- April 1, 2021
.  WHAT CHANGE IS HAPPENING APRIL 1, 2021 Beginning April 1, 2021, a change is coming for New York Medicaid recipients who newly become enrolled in Medicare and become "Dual Eligibles" - someone who has both Medicare and Medicaid. Every month about 3,000 - 4,000 Medicaid recipients in New...
Transition Rights in Managed Care Plans - Rights of New Enrollees to Continue Receiving Services
States must have in effect a transition of care policy to ensure continued access to services during a transition from Fee for Service Medicaid (FFS) to a Managed Care plan or transition from one Managed care plan to another "when an enrollee, in the absence of continued services, would suffer...
KNOW YOUR RIGHTS: Managed Long Term Care - Fact Sheets, Live and Recorded Webinars
A. Fact Sheets on Managed Long Term Care B. Click here for WEBINARS on LONG TERM CARE A. Fact Sheets on Managed Long Term Care BASICS Basics on Managed Long Term Care (In process of being updated - 2-2020) see also Article on Managed Long Term Care News on MLTC - updated monthly ...
Medicaid Alerts & Other Protocols published by the NYC HRA Medical Insurance and Community Services Administration (MICSA)
HRA MICSA Alerts are periodic announcements of policy, staff and office changes published by the Medical Insurance and Community Services Administration (MICSA). MICSA is the part of New York City’s Human Resource Administration (HRA) that administers HRA’s medically- related programs such as...
Medicaid Managed Care
Law and Regulations STATE - N.Y. Soc. Servs. L. §364-j (Amended L. 2011 Ch. 59). Regulations at 18 NYCRR 360-10. FEDERAL - 42. C.F.R Part 438 (amended extensively in 2016, with changes going into effect in NYS on rolling basis, including new appeal rules starting May 1, 2018 requiring...
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...
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...
Transition Rights after Enrolling in or Switching MLTC plans - 2022 Changes
This article can also be downloaded as a Fact Sheet here. If you received Medicaid personal care or Consumer-Directed Personal Assistance (CDPAP) services, and then you were required to enroll in or transfer to a different Managed Long Term Care plan, your new Plan must continue to authorize...
Managed Long Term Care
State Complaint Number for MLTC Problems - 1-866-712-7197 e-mail mltctac@health.ny.gov and put "COMPLAINT" in subject line For enrollment complaints - call NY Medicaid Choice - 1-855-886-0570 (Advocates line) 1-888-401-6582 (Consumers line) Managed Long Term Care (MLTC)...
Special Income Standard for Housing Expenses: If Discharged from Nursing Homes or Adult Homes & Enroll in or Remain Enrolled in MLTC Plan
A huge barrier to people returning to the community from nursing homes is the high cost of housing. One way New York State is trying to address that barrier is with the Special Housing Disregard that allows certain members of Managed Long Term Care or FIDA plans to keep more of their income to pay...
Know Your Rights: NYLAG Webinars on Medicare and Medicaid -
The Evelyn Frank Legal Resources Program conducted a five-part Continuing Legal Education Webinar program in April and May 2016 that provides tools to understand and navigate the complex world of Medicare and Medicaid in New York. The focus is on eligibility and application procedures for older...
Patients' Rights in the Health Care System
Managed Care Bill of Rights New York State has a fairly progressive managed care bill of rights which is found in both the Public Health and Insurance laws. Disclosure. Managed care plans must tell their patients about the coverage offered, benefit packages, prior authorization rules,...
When an MLTC Plan Closes - What are the Members' Rights? WARNING - Changes Now in Effect
Since Managed Long Term Care (MLTC) plan enrollment has been mandatory since 2013 for most adult "dual eligibles" (people with Medicaid and Medicare) who need Medicaid home care, some MLTC plans have either closed or reduced their service area, no longer covering certain counties or New York City....
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...
MLTC Members in Nursing Homes for 3+ Months Being Disenrolled from MLTC Plans - Since August 2020
Starting in August 2020, MLTC members are disenrolled from their plans after a "Long Term Nursing Home Stay" - defined as 3 months in a nursing home and Institutional Medicaid was approved. In December 2019, CMS approved the request by NYS Dept. of Health to "carve out" long-term Nursing Home...
Tools for Choosing a Medicaid Managed Long Term Care Plan
As described in this article, most adults in NYC, Westchester, Nassau and Suffolk counties who have Medicaid and Medicare, who are receiving Medicaid home attendant or housekeeping ("personal care") services through their local Medicaid "CASA" office, or long-term CHHA or adult day care services,...
New "HARP" Plans Roll out for Managed Care Members who need Behavioral Health Services - Services Start January 2016 in NYC
For many years, behavioral health services have been "carved out" of the Medicaid managed care benefit package. This means that most mental health services are accessed on a fee for service basis outside of the member's managed care plan. Posted here are the Medicaid provider billing codes for...
Public Health Insurance Programs in New York State
These materials include an overview of public health insurance programs in New York and in-depth information on Medicaid managed care.
KNOW YOUR RIGHTS: Medicaid Managed Care in New York State
These Fact Sheets on Medicaid Managed Care were written specially for consumers, by Medicaid Matters New York. They are dated October 2011 and will be updated in 2012 to reflect changes. Topics covered include: Included in the document attached are the following fact sheets: Know Your...
Medicaid Managed Care Fact Sheet - Pharmacy Services
Effective October 1, 2011, Medicaid’s pharmacy benefit will be moved into the managed care benefit package. The pharmacy benefit includes all FDA approved prescription drugs, as well as some over-the-counter drugs and medical supplies. The Family Health Plus (FHP) pharmacy benefit, which is less...

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