Requesting a New or Increased Service from a Medicaid Managed Care or MLTC

Members of Medicaid Managed Care plans, including Managed Long Term Care (MLTC) plans, have the right to request a NEW service that was not previously authorized ("prior authorization"), or an INCREASE In a service they already have ("concurrent review"), such as more hours of personal care or consumer-directed personal assistance (CDPAP) 

In this article:

1.  Sources of law

2.  TIME LIMITS FOR PLAN TO PROCESS A REQUEST FOR NEW or INCREASED SERVICES

3.  Model Plan Notices - Managed Care & MLTC

4. What if Plan Does Not Issue a Determination By the Deadline - Member may File a Plan Appeal Anyway

5.  New "Independent Assessor" procedures  for requests for Personal Care or CDPAP, and Tips for requesting increases

6.  More about requesting increases in Medicaid personal care or CDPAP services  what standards are used?

7.  Getting Help - see this article

1. Sources of law: 

2.  TIME LIMITS FOR PLAN TO PROCESS A REQUEST FOR NEW or INCREASED SERVICES

Contract and 42 CFR 438.210 provide that Plan must decide and notify Enrollee of decision by phone and in writing as fast as the Enrollee’s condition requires but no more than the following timeline.

In NYS, these requests have  particular names in the state's contracts with the managed care and MLTC plans:

a.   "Prior authorization" -  a request by the Enrollee or provider on Enrollee’s behalf for a new service (whether for a new authorization period or within an existing authorization period) or a request to change a service as determined in the plan of care for a new authorization period.

b. "Concurrent review "- a request by an Enrollee or provider on Enrollee’s behalf for more services than the amount  currently authorized in the plan of care (such as increased hours of personal care or CDPAPor for Medicaid covered home health care services following an inpatient admission.

14-DAY EXTENSION OF ABOVE DEADLINES including Expedited Requests --  The plan may extend the 72 hour time period for expedited reviews and the 14 day time limit for standard revies by up to 14 calendar days if the enrollee requests an extension, or if the MCO, justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee's interest   42 CFR 438.210(d) 

3.  Model Plan Notices - Managed Care & MLTC

Model notices of approvals or adverse determinations are posted DOH Service Authorizations  & Appeals webpage - for both regular mainstream managed care plans and MLTC plans

If consumer files a Plan Appeal of an Initial Adverse Determination  notice,  then Plan must issue a --

4. What if Plan Does Not Issue a Determination By the Deadline - Member may File a Plan Appeal Anyway

If the plan does not issue a decision on a request for services within the timeframes specified in  42 CFR 438.210 described above, this constitutes a denial and is thus an adverse action, which can be appealed just as a written decision can be appealed.  42 CF.R. 438.404(c)(5).  See article on Appeal & Grievances in MLTC

5.  New "Independent Assessor" procedures  for requests for Personal Care or CDPAP, and Tips for requesting increases

Tips on Requesting Services from a Medicaid Managed Care or MLTC plan, including Increases in Hours of Home Care  (RUSSIAN TRANSLATION  NEW August 2021)

NY Independent Assessor (NYIA)  -- New procedures for how plans assess eligibility for Personal Care and CDPAP. 

6.  MORE ABOUT REQUESTING INCREASES OF HOURS OF HOME CARE

See these parts from our article on Medicaid personal care services, which also applies to CDPAP.  The same rules apply whether the services are obtained through an MLTC or other managed care plan, or from the local DSS.

Fact Sheet: Tips on Requesting Services from a Medicaid Managed Care or MLTC plan, including Increases in Hours of Home Care  (RUSSIAN TRANSLATION  NEW August 2021)

7.    WHERE TO GO FOR HELP 

See this article.


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

NYLAG



Article ID: 233
Last updated: 03 Oct, 2022
Revision: 1
Medicaid -> Home Care -> Requesting a New or Increased Service from a Medicaid Managed Care or MLTC
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