NY Health Access About Us   |   Contact Us Empire Justice Center Legal Aid Society NYLAG WNYLC

Transition Rights in Managed Care Plans - Rights of New Enrollees to Continue Receiving Services

print  Print
share  Share
Views: 10590
Posted: 04 Jun, 2009
by --
Updated: 07 Jul, 2022
by Valerie Bogart (New York Legal Assistance Group)

States must have in effect a transition of care policy to ensure continued access to services during a transition from Fee for Service Medicaid (FFS) to a Managed Care plan or transition from one Managed care plan to another "when an enrollee, in the absence of continued services, would suffer serious detriment to their health or be at risk of hospitalization or institutionalization."  This is required by federal regulations as amended in 2016.  42 C.F.R. § 438.62, and is incorporated in the CMS Special Terms & Conditions  of the waiver that authorizes the managed care program in NYS (Web) - (PDF) (Oct. 2021) (Article V(4)(g) at pp. 32-33). 

  • The transition policy must ensure that the "enrollee has access to services consistent with the access they previously had, and is permitted to retain their current provider for a period of time if that provider is not in the [plan's] network."  42 C.F.R. § 438.62 The transition policy also must ensure that the enrollee is referred to in-network providers.  The new plan and providers must also have  access to the enrollee's previous medical records and plans of care.  

  • Before the federal regulation was enacted in 2016, NY Public Health Law required limited transition rights. Plans have long been required to provide access to a new enrollee's providers who are out of network, under limited conditions.  See  NY Public Health Law § 4403, subd. 6(f).  This was incorporated in a DOH transitional care policy which clarifies that continuity of care includes certified home health agency care, for new enrollees who are receiving an ongoing course of treatment upon enrollment.

Transition Policy Must be Publicly Available  

  • The 2016 federal regulations require, "State must make its transition of care policy publicly available and provide instructions to enrollees and potential enrollees on how to access continued services upon transition. At a minimum, the transition of care policy must be described in the quality strategy, under § 438.340, and explained to individuals in the materials to enrollees and potential enrollees, in accordance with § 438.10."  42 C.F.R. § 438.62(b)(3)

  • NYS has posted its Quality Strategy (updated March 2022). However, the transition rights (page 4 of the PDF) discuss solely the rights described above regarding the right to see out of network providers for 60 days, the rights of pregnant women, and rights if provider leaves network. It does not address consumer rights to continuity of services, not just providers, in  transition from fee for service or from one Managed care plan to another "when an enrollee, in the absence of continued services, would suffer serious detriment to their health or be at risk of hospitalization or institutionalization."  42 CFR 438.62.  The State has issued policies limited to certain situations, such as when an MLTC plan closes - see MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration.  However, these policies fall short of fully protecting enrollees.  See more about MLTC transition rights, with harmful changes effective Nov. 2021, here


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Attached files
item SDOH transitional care policy.pdf (139 kb) Download

Also read
item Medicaid Managed Care
item New York Dramatically Expands Mandatory Managed Care for Medicaid Beneficiaries
item When an MLTC Plan Closes - What are the Members' Rights? WARNING - Changes Now in Effect
item Transition Rights after Enrolling in or Switching MLTC plans - 2022 Changes

Also listed in
folder Medicaid -> Other Services
folder Medicaid -> Home Care

Prev     Next
Medicaid Recipients to be "Default Enrolled" into Medicare...       KNOW YOUR RIGHTS: Managed Long Term Care - Fact Sheets, Live...


This site provides general information only. This is not legal advice. You can only obtain legal advice from a lawyer. In addition, your use of this site does not create an attorney-client relationship. To contact a lawyer, visit http://lawhelpny.org. We make every effort to keep these materials and links up-to-date and in accordance with New York City, New York state and federal law. However, we do not guarantee the accuracy of this information. To report a dead link or other website-related problem, please e-mail us.