As if there’s not enough change, beginning January 2020, about 10% of Managed Long Term Care members now must deal with a new appeal and fair hearing process. These are people in Medicaid Advantage Plus (“MAP”), which consists of a "FIDE-SNP" (Fully Integrated Dual Eligible - Special Needs Plan), which covers the Medicare services, and a Medicaid Managed Care plan that includes a Managed Long Term Care (MLTC) plan. The Medicare and Medicaid services, including MLTC, are all covered by one managed care insurance plan called a MAP. In this article:
1. What are Medicaid Advantage Plus (MAP) plans and how are they different than regular MLTC plans?
There are two types of Medicaid managed care plans that provide Medicaid home care and other community-based long term care services for adult Dual Eligibles in NYS (Dual Eligibles = have Medicare and Medicaid)
Medicaid Advantage Plus (MAP) plans are “Fully Capitated” plans
These plans combine in one plan a Medicare Advantage Plan, an MLTC plan and a Medicaid managed care plan. "Capitation" is the monthly premium a plan receives from the government to provide a package of services. "Full capitation" means that the plan receives a monthly "capitation" premium from both the federal and state government to provide ALL Medicare and Medicaid services.
See helpful info on ICAN website --What kinds of MLTC plans are there?
The plan is responsible for authorizing and paying for ALL Medicare and Medicaid services, including the services normally provided by an MLTC plan. The member must use only providers that are in the plan's provider network. This is true for Medicare and Medicaid providers.
HOW MANY NEW YORKERS ARE IN MAP PLANS? And Where are the MAP Plans?
There are nearly 25,000 people in 10 MAP plans as of January 2021 – all but 800 of those are in NYC. See DOH monthly enrollment stats (Download document for most recent month -- Tab named Medicaid Advantage Plus shows number enrolled in each plan in NYC and in each county).
Only 10 counties outside NYC have MAP plans as of January 2021.
ARE THERE OTHER "FULLY CAPITATED PLANS" LIKE MAP PLANS?
Yes. PACE plans are "fully capitated plans like MAP plans and also are only for people who need Medicaid long term care services, and the plans cover all Medicare and Medicaid services. Three are only 5,500 New Yorkers in PACE plans in NYC and 16 other counties as of January 2021 (See DOH monthly enrollment stats (download most recent document -- On tab for Managed Long Term Care look at the TOP for PACE enrollment - number enrolled in each plan in NYC and in each county).
The FIDA program was similar to MAP, but was a demonstration program that closed at the end of 2019.
Managed Long Term Care (MLTC) or "Partially Capitated" plans
Most adults who have Medicare and need community-based long term care services are in “partially capitated” MLTC plans. This means the plan receives a monthly "capitation" premium payment from NYS only for the Medicaid long term care services in the MLTC benefit package. Members of MLTC plans have their Medicare coverage separate – they can choose to have Original Medicare or Medicare Advantage.
HOW MANY NEW YORKERS ARE IN MANAGED LONG TERM CARE PLANS?
In January 2021, there were 244,000 MLTC plan members in NYS, of which almost 194,000 are in New York City.
LISTS OF PLANS BY AREA IN NYS
For a list of MAP plans in your area, go to https://www.nymedicaidchoice.com/choose/find-long-term-care-plan and enter your county or for lists of plans by area go to https://nymedicaidchoice.com/program-materials and scroll down to Long Term Care Plans in your area. Here is NYC:
MAP members who want to appeal an adverse decision by the MAP plan denying or reducing Medicaid personal care or CDPAP services (or any other plan services) must use a NEW appeal and hearing procedure that is slightly different than the regular OTDA Fair Hearings used for MLTC. In both MAP and MLTC, “exhaustion” of the plan appeal is required first before a fair hearing. See article on MLTC appeals and exhaustion.
MORE ABOUT MAP HEARING PROCEDURES
Mail: Integrated Appeals/IAHO-10A, P.O. Box 1930, Albany, NY 12201
MAP: IAHO 1 (844) 523-8777
MLTC: OTDA OAH 1 (800) 342-3334
There are two important benefits of Varshavsky that as of now apply only to people in MLTC and not MAP plans. See Varshavsky fact sheet for more about these benefits.
See Varshavsky Fact Sheet with more info and tips.
Both the MLTC FAD notice and the MAP-FIDE Plan Appeal Decision notice (in this zip file) explain that the member has the right to file an External Appeal with the NYS Dept. of Financial Services, which is NYS's insurance department. External appeals may only be used if the denial was based on lack of medical necessity, but this is generally the issue in these appeals. The appeals are solely on paper so strong documentary evidence is needed.
If the "expedited" external appeal track is used, a decision may be issued in a matter of days - much faster than a fair hearing. If the external appeal decision is favorable, it is binding on the plan, and the fair hearing request may be withdrawn.
If the external appeal is decided adversely, the enrollee still may do the fair hearing. Since these take a long time to schedule, it is recommended to request the fair hearing first, then file and pursue the External Appeal while the Fair Hearing is pending.
Medicare Rights Center has created a toolkit with resources about MAP benefits, consumer rights and appeals. On that webpage you will find links to fliers:
FIDA (*transitioned 12/31/2019*) and NY Integrated Appeals and Grievances Demonstration
On January 1, 2020, CMS and NYSDOH transitioned remaining FIDA enrollees to MAP plans and aligned D-SNPs. This transition also included extending the FIDA integrated appeals and grievances process to MAP and aligned D-SNP plans. Under the revamped NY Integrated Appeals and Grievances Demonstration, CMS and NYSDOH are testing the integrated appeals and grievances process begun under FIDA with a larger volume of full benefit dual eligible individuals. As of January 2020, approximately 18,000 individuals are enrolled in a MAP and aligned D-SNP plan.
Information from CMS on NY Integrated Appeals and Grievances Demonstration: