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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: 

  • 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)

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.

  • 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 CDPAPor 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) 

  • The plan must give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision; and Issue and carry out its determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.  42 CFR 438.404(c).  

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

  •  Initial Adverse Determination
    • Denial Notice - (Web) - (PDF) - 11.4.2021
    • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021 (has Aid Continuing rights)
  • Approval Notice - (Web) - (PDF) - 11.20.2017
  • 14-day Extension Notice - (Web) - (PDF) - 11.4.2021

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

  •  Final Adverse Determination (this is after a Plan Appeal - see article on appeals)
    • Denial Notice - (Web) - (PDF) - 11.4.2021
    • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021 (has Aid Continuing rights)

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. 

  • What is the Independent Assessor?  Click here for the basics

  • 2 State websites on NYIA  - Maximus website - https://nyia.com/en  (also in Espanol) (launched June 2022) and STATE website on Independent Assessor with government directives here 

  • 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.

  • For more info see this link. - including NYLAG advocacy on NYIA, PowerPoints with more info, WHERE TO COMPLAIN about delays, and other problems.

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


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