Coming July 1st: MLTC Members May Request Fair Hearing Without first Requesting Internal Appeal from Plan ("Exhaustion" Requirement ELIMINATED)

Managed Long Term Care Appeals System Change

Exhaustion Requirement to be Eliminated Effective July 1, 2015

Since early June 2015, everyone in Managed Long Term Care (MLTC) plans have been receiving a notice from their MLTC plan that looks like this sample notice.   This notice has caused a lot of confusion.   The notice is about a change in the appeals process generally. It is not a notice that any individual member's services are being reduced.  Here is information about the change.  More about the Grievance and Appeals process in MLTC is posted in this article.

Until now, consumers whose home care hours were reduced by their MLTC plan had to request an "internal appeal" by the plan to reconsider its decision before requesting a fair hearing against the plan.   The New York State Department of Health announced by webinar on April 29, 2015 that this requirement would be eliminated on July 1, 2015.  The webinar and accompanying slides are available on the MRT 90 website under "Partial Capitation Model Action Notices."

MLTC Plans are tasked with notifying their enrollees about this change.  DOH required plans to send this model notice on plan letterhead to all enrollees in early June 2015 in order to alert them to this change and the consequences that flow from this change.  The notice is discussed at slides 11 and 12 of the webinar.  Plans are encouraged to not rely solely on this notice when educating enrollees about this change. 

The changes effective July 1, 2015 are as follows:

MLTC members can still request an internal appeal instead of, or concurrently with, a fair hearing, BUT NOTE:

Plans must send notices of any reduction or termination of services at least 10 days before the effective date of the change.

For more on appeals see this article.

New Model Notices Effective for Actions Starting July 1, 2015 (MLTC Plans ONLY - not FIDA)

DOH announced in the same webinar that, starting July 1, 2015, plans must use two new model notices when making any decisions that are adverse to the consumer.  Both of the 2 notices described below, along with DOH samples of how the templates are used, are posted in this PDF, along with the March 2015 State directive to plans enclosing the notices.

Plans are responsible for translating the notices into prevalent languages  (See Q. 11 in accompanying FAQ on MRT 90 website).

Adverse determinations triggering these notices continue to include most actions defined in Appendix J of the Model Contract:

The following actions DO NOT require use of the new model notices, but may in the future:

Note: these new notices are for Partially Capitated Plans only, which means MLTC plans, not Medicaid Advantage Plus or PACE plans.  FIDA notices are different as well.


11 Jun, 2015
Coming July 1st: MLTC Members May Request Fair Hearing Without first Requesting Internal Appeal from Plan ("Exhaustion" Requirement ELIMINATED)