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

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Posted: 21 Aug, 2020
by Valerie Bogart (New York Legal Assistance Group)
Updated: 24 Aug, 2020
by Joe Kelemen (New York Legal Assistance Group)

ALERT:  Medicare Rights Center is doing a WEBINAR on MAP APPEALS on SEPTEMBER 1, 2020.  Register here. 

As if there’s not enough change,  beginning January 2020, about 10% of Managed Long Term Care members now must deal with a new fair hearing process.   These are people who are in Medicaid Advantage Plus (“MAP”) plans.  These are “Fully Capitated” plans that combine in one plan a Medicare Advantage Plan, an MLTC plan and a Medicaid managed care plan.  See helpful info on ICAN website  --What kinds of MLTC plans are there? 

  • Medicare Rights Center is doing a WEBINAR on MAP APPEALS on SEPTEMBER 1, 2020.  Register here. 

Most people are in “partially capitated” MLTC plans which means they have their Medicare coverage separate – whether through Original Medicare or Medicare Advantage.  But nearly 22,000 are in MAP plans – all but 700 of those are in NYC.  See DOH monthly stats (Tab for Medicaid Advantage Plus shows  number enrolled in each plan in NYC and county).

MLTC Medicaid Plans - New York City

Medicaid Advantage Plus - New York City

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

  • Note that most MAP plans are operated by insurance companies that also operate MLTC partially capitated 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 both MLTC ("VNS CHOICE") and a MAP plan ("VNS CHOICE PLUS").  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.  

  • Of the 10 MAP plans now operating in the State, 8 have been approved for this new appeal process.  The two that are NOT yet approved are FIDELIS (which had only 63 members statewide in July 2020 - half of which are in NYC and the rest in Albany, Montgomery, Schenectady & Rensselaer Counties, and HEALTHPLUS (Empire Blue Cross Blue Shield) with only 12 enrollees only in NYC.  

    Since Jan. 2020, MAP members in the 8 approved plans who want to appeal an adverse decision denying or reducing Medicaid personal care or CDPAP services (or any other  plan services) must use a NEW 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" appeals - Fully Integrated Dual E??.  

  • The increased enrollment in MAP is mostly due to the closing of the FIDA plans.  All during 2019, the FIDA plans informed their members that they were closing and that the members could switch to their Medicaid Advantage Plus product.  The last few remaining FIDA members were assigned to MAP plans.  Unlike FIDA, which was limited to NYC, Long Island and Westchester,  MAP  is a statewide program -so advocates statewide need to learn about this new appeal process. See Medicare Rights Center Fact Sheet on  Medicaid Advantage Plus (MAP) appeals

INFORMATION 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:

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:

Also read
item Managed Long Term Care
item Appeals & Grievances in Managed Long Term Care - "Exhaustion" of Plan Appeal Required since 2018

Also listed in
folder Medicaid -> Medicaid Managed Care

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