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 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.
NEW May 2022 - CMS Issues brief Report on Financial Alignment Initiative for Medicare-Medicaid Enrollees New York Integrated Appeals and Grievances Demonstration - First Brief Report (PDF) Related content: Financial Alignment Initiative for Medicare-Medicaid Enrollees
In this article:
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 certain kind of 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.
"DUAL FIDE SPECIAL NEEDS PLANS" - Only Medicare Advantage Plans that are "Dual-SNP's" or DUAL-Special Needs Plans may become MAP plans. Further, it can't be any Dual-SNP. It must be a Fully-Integrated Dual Eligible Special Seeds Plan (FIDE SNP). Some other Dual-SNPs are not fully integrated, meaning they may cater to people with Medicare and Medicaid but are not combined Medicare/Medicaid plans integrating both benefit packages.
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 are links for NYC:
Also see this NYS MAP list, which NYLAG compiled from NYS DOH MLTC list. This list also identifies the Name and ID number of the Dual-SNP plan that the member joins when they join a MAP plan, and also the counties in which these plans are enrolling people in 2021-2022.
List of all SNP's in NYS (2021) (2022) - shows which plans in your county are FIDE SNPs - only these can be MAP plans. A few are "HIDE" SNP's - Highly Integrated SNPs. This list also has some SNP's that are not D-SNPs - they are for I-SNPs for Institutionalized people or Chronic Care SNPs.
HOW MANY NEW YORKERS ARE IN MAP PLANS? And Where are the MAP Plans?
There are nearly 31,000 people in 10 MAP plans as of Sept. 2021 – all but 1,100 of those are in NYC.
This is compared to about 245,000 in regular MLTC plans. 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 12 counties outside NYC have MAP plans as of Sept. 2021.
Find lists of MAP Plans here. with counties covered.
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 Sept. 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.
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
3. WARNING re Varshavsky case and Home Hearings: Members of regular MLTC plans have some special hearing rights under a class action called Varshavsky v. Perales. That decision held that Medicaid recipients who cannot travel to a hearing without substantial hardship because of a disability have the right to a hearing held in their home, if an initial hearing held by phone is not decided fully favorably. The State is taking the position that Varshavsky does not apply to MAP-FIDE hearings.
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.
4. INFO from Medicare Rights Center about MEDICAID ADVANTAGE PLUS CONSUMER RIGHTS, BENEFITS & APPEALS
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:
5. FEDERAL CMS GUIDANCE on NY Integrated Appeals and Grievances Demonstration:and MODEL FORMS
CMS Webpage on Integrated Financial Alignment Initiatives for Dual Eligibles
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.
Federal regulations - The MOU refers to 42 C.F.R. 422.633, which was amended on Jan. 19, 2021, as part of new requirements applicable to certain Integrated Dual Eligible Special Needs Plans. See 86 FR 6103
NEW May 2022 - CMS Issues brief Report on Financial Alignment Initiative for Medicare-Medicaid Enrollees New York Integrated Appeals and Grievances Demonstration - First Brief Report (PDF)
The Healthfirst MAP plan failed to "auto-forward" appeals for 789 members to the Integrated Administrative Hearings Office (IAHO), which is administered by NYS OTDA, under the process described below. As a result, hearings to appeal the "Appeal Decision Notice" by the plan were never scheduled (this is the equivalent of the Final Adverse Determination for MLTC plans). About 75% of these appeals involve the plan's denial of an increase in home care hours (personal care or CDPAP). The rest involve denial of one-time requests like medical supplies or equipment, or other issues.
To remedy this mistake, the State Dept. of Health has ordered this plan to give a "temporary approval" of the requested increase in hours now until the end of the current authorization or the next assessment, whichever is sooner. See letter sent by Healthfirst MAP to members. If at the next assessment the plan determines that a reduction is justified, it may reduce services. Advocates have asked DOH to confirm that the plan may only reduce services at the reassessment for reasons outlined in DOH MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services, and must provide advance notice of the proposed reduction with Aid Continuing rights.
Also, the plan must reimburse members who paid out of pocket for the requested increase in services after the adverse "Level 1" decision and prior to March 24, 2021.