In July of 2015, New York State began to see a roll-out of new provisions which governed Medicaid coverage of long-term care for the elderly and disabled populations as part of an effort to redesign the program and balance costs. Under the new 2015 programs, anyone in the aged (65 years or older), blind, or disabled categories who was eligible for both Medicare and Medicaid and in need of 120 days or more of skilled nursing care per year was required to enroll in a Medicaid Managed Long-Term Care (MLTC) plan. This type of plan handled coverage for individuals whether they lived at home and received home care services, or whether they lived in a nursing home. If you were unhappy with your MLTC plan or needed to switch plans for any reason, you had the option of disenrolling and choosing a new plan any time.
Whether you had Fee-for-Service Medicaid or MLTC, you had the right to immediately request a Fair Hearing with an Administrative Law Judge from the NYS Office of Temporary and Disability Assistance if you disagreed with a decision made by your plan. You also had the right to request an internal appeal with your plan, but whether you requested this did not have any effect on your right to an external Fair Hearing.
This year, with the recently enacted 2018-2019 State Budget, the tides have once again shifted, bringing many new changes to this system into play. It is vital for anyone currently receiving Medicaid or who anticipates a future need for Medicaid coverage to understand their coverage and their rights under the program. While this article provides general information about the new rules and procedures, we strongly urge you to reach out to the staff of the Center for Elder Law & Justice if you have any specific questions about your coverage or appeal rights.
Changes to MLTC Plan Eligibility and Enrollment – Effective April 1, 2018
- MLTC plans are now essentially only for individuals applying to receive homecare services. There is limited coverage of nursing home stays, but only if the stay is temporary.
- For a new long-term nursing home Medicaid applicant, the type of Medicaid to apply for is Fee-for-Service Medicaid. If you are already on an MLTC plan when you enter the facility, you will be transitioned into Fee-for-Service Medicaid after 3 months of permanent institutionalization (or a long-term stay).
- All MLTC enrollees who are permanently institutionalized or begin a long-term institutionalization in a nursing home any time from April 1 forward will be disenrolled from their MLTC plan as of July 1, 2018 (or 3 months from the date of enrollment, whichever is later) and placed on Fee-for-Service Medicaid. You should receive information about this transition from your MLTC plan.
- After initial enrollment, enrollee has a very short window to switch MLTC plans. From there, the enrollee is locked into their plan for 12 months.
Changes to MLTC Plan Appeal Rights and Procedures – Effective May 1, 2018
- Enrollee is entitled to written notice at least 10 days before the plan says it will reduce or stop any services (this is unchanged).
- EXHAUSTION REQUIREMENT: Enrollee MUST first request an Internal Plan Appeal and receive a Final Adverse Determination BEFORE requesting a State Fair Hearing. Enrollee has 60 days to make this request.
- Enrollee may request an Internal Plan Appeal orally via telephone, but must follow up an oral request with a written request by mail or fax. Enrollee must give written authorization to anyone requesting an appeal on their behalf, or the appeal may not be processed.
- Aide Continuing (the request to ensure your services remain in place and unchanged until a final determination has been made) must be requested twice during the appeals process – you must request aide continuing directly from the plan before the proposed reduction or denial goes into effect – essentially, Enrollees have approximately 10 days to request aide continuing at this stage. Once you receive a Final Adverse Determination from the Plan, you must again request aide continuing from OTDA when you request a State Fair Hearing. This request must also occur within 10 days of the Final Adverse Determination, even though you have 120 days to request a Fair Hearing.
- Enrollees have 120 days to request a State Fair Hearing (changed from 60 days) from the date of the Final Adverse Determination. Only Exception: if Plan fails to timely respond to Internal Plan Appeal, Enrollee may request a State Fair Hearing without receiving a Final Adverse Determination from the Plan.
- Note: Even if a Plan fails to issue a Notice for an action, such as a reduction in services, the Enrollee still must request an Internal Plan Appeal. If the Plan fails to process such an appeal, the Enrollee may request a State Fair Hearing and argue that “exhaustion” has been deemed by the Plan’s failure to respond.
*Disclaimer: This is general Medicaid information and not to be construed as legal advice. Since every case is different, we advise clients to call about specific circumstances. This information is subject to change at any time.
About the Author
This post was written by Kelly M. Barrett, Esq., who has served as an attorney in CELJ’s Health Care Advocacy Unit since October 2015. Kelly represents clients in appeals and grievances involving Medicaid, Medicaid Managed Long Term Care, Medicare, and private health insurance companies. Kelly also serves in number of coalitions that advocate for clients’ healthcare rights in New York State, and serves on the Steering Committee for Medicaid Matters New York.