Medicaid Advantage Plus "MAP" - New "FIDE" Appeals & Hearing Process began 2020

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:

• Background on MAP plans and how they are different than MLTC plans. 
• The new Integrated Appeal Aystem, 
• Warning about rights under the Varshavsky v. Perales case on Home Hearings. 
• Gact sheets by the Medicare Rights Center, 
• Federal CMS  MAP Guidance and "MOU" governing MAP plans and model notices. 

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. 

• If they choose Original Medicare, they may use any provider who accepts Medicare.  There is no "provider network." 
• If they choose Medicare Advantage, they must use providers in their chose plan's network.  Some Medicare Advantage plans are Preferred Provider Organizations (PPO) and allow using providers out of network, usually at a higher out-of-pocket cost.  

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:

• Long Term Care Plans in New York City

MLTC Medicaid Plans - New York City

Medicaid Advantage Plus - New York City

Program of All-Inclusive Care for the Elderly - New York City

• WARNING - PLAN NAMES ARE CONFUSING!!   Most MAP plans are operated by insurance companies that also operate MLTC partially capitated plans and other plans, such as Medicare Advantage plans.  It can be difficult to tell one from the other.  The lists at the links above show that they have slightly different names.  When you ask your client what plan they are in, it is not enough to say "VNS CHOICE" since that company operates an MLTC ("VNS CHOICE")  and a MAP plan ("VNS CHOICE TOTAL"). All of these companies  also operate Medicare Advantage plans.  One type of Medicare Advantage plan is a Dual-Special Needs Plan ("Dual-SNP").  It is this type of Medicare plan that the member joins when they join a MAP Plan - and the DUAL-SNP is linked to their Medicaid managed care plan that includes MLTC.  

2.  NEW APPEAL AND HEARING SYSTEM FOR MAP PLANS started 2020 

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.

• The new Integrated Appeal process essentially continues the integrated procedure that was used in the FIDA demonstration program, that ended  Dec. 31, 2019.  OTDA calls it "FIDE-SNP" appeals - Fully Integrated Dual Eligible - Special Needs Plan.  

• How is the MAP-FIDE Appeal System Different than MLTC Appeals and Hearings?

1. Initial adverse notice  (request for new or incresed service or notice of reduction) -  

• MLTC Notice called "Initial Adverse Determination" or IAD - Model denial IAD and  Model reduction IAD

• MAP notice called "Coverage Determination Notice" - download Integrated Beneficiary Notices (ZIP) 

• in both, member must request an internal appeal within the plan, and has the right to Aid Continuing if the appeal is requested before the Effective Date of a proposed reduction (10-day advance notice required of a reduction)

2. Plan Notice Denying Internal Plan Appeal - 

   • MLTC Notice Called "Final Adverse Determination" or FAD -  Model Denial FAD  and  Model Reduction FAD  -

   • MAP "Appeal Decision Notice" --  download Integrated Beneficiary Notices (ZIP) 

3. Hearing -  Two different hearing  systems for MLTC and MAP - 

   • MLTC - Member must request a Fair Hearing with NYS OTDA like any other Medicaid hearing.  If the action is a threatened reduction, member must request the hearing in time to get Aid Continuing - before the Effective Date of the reduction.  

   • MAP "FIDE" Hearings - are held by the Integrated Administrative Hearings Office (IAHO), which is administered by NYS OTDA through a separate system than regular Medicaid fair hearings.  The procedures and timing requirements for  the IAHO hearings are in the Memorandum of Understanding (MOU) between the NYS Dept. of Health and CMS that governs the integrated hearings demonstration.   

     1. Within 2 business days after its adverse Appeal Decision, the plan must  AUTOMATICALLY forward the case  and the case file to the IAHO, which serves as the request for the hearing.  MOU Appendix 3,  Section 3.4.1.1. The MAP member does NOT have to request this hearing.  

     2. ​​​​​​​Within 14 calendar days of forwarding the administrative record  to the IAHO, the plan must send the member an Acknowledgement of Automatic Administrative Hearing and Confirmation of Aid Status with a copy to the IAHO. MOU Appendix  3, Section 3.4.4.; 3.5.1. The notice should advise the member that if the do not hear from OTDA about scheduling the hearing within 10 days (24 hours for expedited appeals), the member should call the IAHO. 

     3. OTDA is supposed to send the member and plan notice of the hearing 10 days in advance.  MOU Appendix 3, Section 3.5.2.

4. ​​​​​​​​​​​​​​​​​​​​​ EXTERNAL APPEAL - ALTERNATIVE to FAIR HEARING - or IN ADDITION TO HEARING  - See info here. 

MORE ABOUT MAP HEARING PROCEDURES 

• Obtaining the Evidence Packet for the Hearing -  

  • MAP plan SHOULD send it automatically to the member, without having to request it.  See the sample Appeal Decision Notice.  The MOU at pagd 3 specifically requires MAP plans to comply with other requirements in the managed care regulations - 42 C.F.R. Part 438, which requires plans to provide the case file during the plan appeal. 

  • MLTC - Plan SHOULD have provided the member with their file during the course of the initial plan appeal.  42 CFR 438.406(b)(5).  If plan did not, member has right to request it for the hearing.  

• Submitting Evidence for the Hearing - because of COVID-19, all hearings are being held by phone.  See 20 GIS TA/DC 097 – NYS OTDA Office of Admin. Hearings (OAH) Transmittal 20-05 - Allowing or Requiring Fair Hearing Appearances by Written, Telephonic, Video, or other Electronic Means.  

  • MAP - Submit evidence by FAX:  518-473-8783 Email:  otda.sm.MAP.Integrated.Appeals.Office@otda.ny.gov  

Mail: Integrated Appeals/IAHO-10A, P.O. Box 1930, Albany, NY 12201

• MLTC - FAX 518-473-6735  or 

​​​​​​​Email:  otda.sm.fhdocuments.submissions@otda.ny.gov

• Phone Contact to OTDA re Scheduling, Adjournments, Etc.

MAP:  IAHO           1 (844) 523-8777

MLTC: OTDA OAH 1 (800) 342-3334

• Deadline for IAHO Decision - As in all Medicaid hearings, a final hearing decision must be made in 90 days from the hearing request (or plan's automatic referral for the fair hearng).  MOU Appendix 3 Sec. 3.6.1
• 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. 

• First, a decision after a phone hearing can only be issued if it is fully favorable.  If it is not fully favorable, the decision cannot be issued, and the case must be scheduled for an in-home hearing. 
• Second,  even before COVID-19 there were long delays in scheduling home  hearings, which must be held and decided within 90 days under the class injunction.  Therefore, in any case where the appellant is classified as "homebound,"  45 days after the hearing was requested,  NYS OTDA orders interim relief.  If the issue of the hearing was denial of an increase in Medicaid personal care or CDPAP services, the interim relief, sometimes known as "Varshavsky Aid Continuing"  requires the plan (or HRA/DSS if that's who denied the increase) to temporarily increase the care to the amount requested, until the home hearing is held and decide.  This interim relief is also ordered in the first situation above, where the "phone hearing" cannot be decided fully favorably, and the case is scheduled for an in-home hearing.

See Varshavsky Fact Sheet with more info and tips.

OPTIONAL STEP WHILE FAIR HEARING PENDING - EXTERNAL APPEAL ​​​​​​​​​​​​​​

​​​​​​​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.

See more about these appeals here.  The State DFS External Appeal website is here.  

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:

• MAP consumer factsheet
• MAP advocate factsheet
• Transitions for FIDA beneficiaries in 2019
• Important long-term care definitions
• Coverage options for dually eligible New Yorkers FAQ
• Medicaid Advantage Plus (MAP) appeals

FEDERAL GUIDANCE and MODEL FORMS 

https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/New-York

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:

• 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
• Memorandum of Understanding (MOU) (PDF)  - between NYS and CMS
• Integrated Beneficiary Notices (ZIP) (including):
  • • Integrated Coverage Determination Notice
    • Expedited Appeal Request Denial Notice
    • Appeal Extension Notice
    • Appeal Denial Notice
• CY 2020 Evidence of Coverage (Chapter 9 (DOCX))
• MAP Handbook Addendum (DOCX)
• CY 2020 Annual Notice of Changes (DOCX)