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Appeals & Grievances in Managed Long Term Care - Consumer Rights: July 1, 2015 CHANGES!!
Procedures to appeal decisions by Managed Long Term Care plans are different than those they are used to from the longtime system of requesting hearings to appeal decisions by the CASA/Medicaid offices.
In March 2015 State Dept. of Health issued new Notice Templates to the MLTC plans, described further below and posted here.
You or someone on your behalf can file a grievance with the plan in writing, over the phone or in person. Your member handbook or member services representative should explain how to file the grievance.
For most plans, one requests a grievance or appeal by calling the member services telephone line. A consumer must be assertive in requesting that they be referred to file a Grievance or Appeal, and know the difference. Otherwise, the call may never be routed correctly.
TIMING: The plan must decide your grievance within 45 days after receiving the information they need to decide and no later than 60 days. If you or your provider think that a delay in deciding the grievance would result in serious harm to your health or ability to function, you can request an expedited grievance. The plan must decide expedited grievances within 48 hours of receiving information needed, and within no more than 7 calendar days.
If you are not satisfied with how your grievance is handled, or it is an emergency, you can also call the State Department of Health MLTC Complaint Hotline at 1-866-712-7197.
If you do not agree with the grievance decision you can file a grievance appeal. You must do so within 60 days of receipt of the grievance decision. Grievance appeals can also be expedited.
How to Appeal an MLTC Decision
Effective July 1, 2015 it will no longer be required to request an INTERNAL APPEAL first, before requesting a FAIR HEARING. If you request both, you get two bites at the apple.
How you should appeal depends on whether the plan is DENYING a service or REDUCING OR STOPPING a service.
A. If plan is REDUCING or STOPPING a service --
MLTC Policy 14.05: Aid-continuing
MLTC Policy 14.05(a): Proper Handling of Enrollees´ Request for Fair Hearing
4. OPTIONAL INTERNAL APPEAL - While you are waiting for the fair hearing to be scheduled, you may request an internal appeal if you want. You do not have to. The internal appeal must be requested within 45 calendar days of the date of the notice. Partial Capitation Contract App. K Sec. I.B (p. 127 of the PDF) If you win the internal appeal, you can withdraw your Fair Hearing request. If you do not win, you go to the hearing when scheduled. But if you request an internal appeal first, you will not get Aid Continuing.
B. If the plan denied a new service, denied an increase in a service, or did not approve enough services -
HOW TO REQUEST THE INTERNAL APPEAL:
You may either -
1. Call the member services phone number of your plan. Ask if you need to confirm your request in writing and ask for the address, fax number, and/or email, OR
2. Write to your plan. Write to Member Services return receipt requested and write APPEAL REQUEST on the envelope and on the letter. Make sure you include your Member ID number, name, address, Medicaid number, phone number, and the reasons for your appeal.
WHEN TO REQUEST THE INTERNAL APPEAL: If the plan denied an increase or a new service, request it with in 45 days of the postmark date of the notice. Partial Capitation Contract App. K Sec. I.B (p. 127 of the PDF). IF plan is reducing or terminating a service, request it BEFORE THE EFFECTIVE date of the reduction but also request a FAIR HEARING before the effective date of the reduction.
WHEN MUST PLAN DECIDE INTERNAL APPEAL and RIGHT TO REQUEST AN EXPEDITED APPEAL:
The Plan must decide an expedited appeal within 2 business days of receipt of necessary information, but no later than 3 business days of receipt of appeal request. Partial Capitation Contract App. K Sec. I.B (p. 127 of the PDF). Plan must make a reasonable effort to give oral notice for expedited appeals and must send written notice within 2 business days of decision for all appeals
YOU HAVE THE RIGHT TO EXAMINE AND RECEIVE COPIES OF YOUR CASE FILE for your appeal and your Fair Hearing.
HOW TO REQUEST A FAIR HEARING:
§ In person: 14 Boerum Place (NYC) or, if you are outside NYC, your Local Department of Social Services
§ By fax: (518) 473-6735 (Download form http://otda.ny.gov/oah/FHReq.asp)
§ By telephone: (800) 342-3334
§ Online: http://otda.ny.gov/oah/FHReq.asp
§ By mail: New York State Office of Temporary and Disability Assistance
OPTIONAL THIRD WAY TO APPEAL -- REQUEST AN EXTERNAL APPEAL (OPTIONAL).
The plan’s notice denying your Internal Appeal will explain your right to request an External Appeal, if the reason for the denial is because they determine the service is not medically necessary or is experimental or investigational. You may request an External Appeal even if you also request a Fair Hearing. External Appeals are reviewed by a different State agency than Fair Hearings. If you request both an External Appeal and a Fair Hearing, the decision from your Fair Hearing will be the one that is followed by your plan.
MLTC Policy 13.01 REVISED: Transition of Care for Fee for Services Participants in Mandatory Counties dated Feb. 6, 2013 -- further clarifies a previous Jan. 17, 2013 Directive -
Both the Jan. 17th and Feb. 6th directives remind MLTC plans that they are required to continue previously authorized long-term care services unchanged for 60 days when a consumer initially transfers into MLTC plans. This is called the Transition Period, required in the CMS Special Terms and Conditions approving the MLTC Waiver. p. 17 par. 28(d). These directives remind plans of their obligation to provide notice before reducing services at the end of the 60-day transition period. They must continue services unchanged during the internal appeal and until a hearing is decided, known as “Aid Continuing,” when a member appeals the plan's proposed reduction e or terminate a service.
The directive states:
This means that, for any individual receiving fee for service Medicaid community based long term
services and supports and enrolling under any circumstance, the plan must provide 60 days of continuity
of care. Further, if there is an appeal or fair hearing as a result of any proposed Plan reduction,
suspension, denial or termination of previously authorized services, the Plan must comply with the aid
to continue requirement identified above. In particular, if the enrollee requests a State fair hearing to
review a Plan adverse determination, aid-to-continue is to be provided until the fair hearing decision is
The revised directive of Feb. 6th clarifies that the requirement to continue past services unchanged for the first 60 days of MLTC enrollment applies to these services:
NYS DOH Model Contract -Partial Capitation Plans - Appendix K
NYS Public Health Law § 4403, 4403-f
CMS Special Terms and Conditions approving the MLTC Waiver (amended Sept. 2012)
NYS DOH MLTC Policy 13.01 REVISED: Transition of Care for Fee for Services Participants in Mandatory Counties dated Feb. 6, 2013
WHERE TO GO FOR HELP
ADVOCATES for New York City Only
NON-LEGAL ADVOCACY ORGANIZATIONS
There are other organizations who can provide non-legal advocacy assistance, such as independent living centers. For a list of local centers, visit http://www.nysilc.org/directory.htm.