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:
3. Model Plan Notices - Managed Care & MLTC
Federal regulations at 42 CFR 438.210 (amended in 2016 effective in NYS May 1, 2018)
NYS Public Health Law Sec. 4903 (in some cases has stricter deadlines than federal regulations)
State's Model contracts with the plans
MLTC contracts at this link under "Model Contracts"
MLTC Model Contract - For 1.1.22 - 12.31.26 - see Appendix K - #3. "Service Authorizations) (pp. 173-176 of the PDF)
"Mainstream" Managed Care contracts with plans posted here
Contract s amended, effective April 1, 2021 -see Appendix F (starts p. 332 of the PDF)
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.
Expedited - 72 hours from request for service, subject to 14-day extension described below, if:
If the member or provider request that a request be expedited, plan must decide request in 72 hours if the plan determines or the provider indicates that a delay "would seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function." If the plan denied the Enrollee’s request for an expedited review, the plan will handle as standard review.
Standard – within 3 business days of receipt of necessary information, but no more than 14 calendar days of receipt of request for services, subject to extension described below.
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 CDPAP) or for Medicaid covered home health care services following an inpatient admission.
Expedited – within 72 hours of receipt of request, on, subject to up to 14-day extension described below.
same standard as for expedited prior approval requests above
Standard – within 14 calendar days of receipt of request, subject to up to 14-day extension described below.
In a request for Medicaid covered home health care services following an inpatient admission, one (1) business day after receipt of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in any event, no more than three (3) business days after receipt of the request for services. NYS Pub. Health Law Sec. 4903, subd. 3
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)
If consumer files a Plan Appeal of an Initial Adverse Determination notice, then Plan must issue a --
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.
NY Independent Assessor (NYIA) -- New procedures for how plans assess eligibility for Personal Care and CDPAP.
What is the Independent Assessor? Click here for the basics.
May 16, 2022 -- was the start date for Independent Assessor being used for:
MLTC enrollment and all
NEW requests for Personal Care and CDPAP made to mainstream or HARP plans on a STANDARD timeframe (not EXPEDITED requests)
Oct. 1, 2022 - Expedited requests for NEW prior authorizations for Personal Care and CDPAP services made to mainstream or HARP plans.
NO DATE YET ANNOUNCED - NYIA will take over all requests for increases (Concurrent review) to MLTC plans for increased personal care or CDPAP services, and annual renewal assessments. PLANS will still make the final determinations about hours or eligibility for services, but the nurse and medical assessment for the services will be done by NYIA.
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.
Standards for 24-Hour Care - Definition of Live-in and Split Shift
See this article.
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.