In 2020, a new appeal and fair hearing process launched for about 10% of Managed Long Term Care members — those who are in Medicaid Advantage Plus (“MAP”), which consists of a “FIDE-SNP” (Fully Integrated Dual Eligible – Special Needs Plan) that covers the Medicare services, and a Medicaid Managed Care plan that includes a Managed Long Term Care (MLTC) plan. The Medicare and Medicaid services, including MLTC, are all covered by one managed care insurance plan called a MAP.
The Healthfirst MAP plan failed to “auto-forward” appeals for 789 members to the Integrated Administrative Hearings Office (IAHO), which is administered by NYS OTDA, under the process described below. As a result, hearings to appeal the “Appeal Decision Notice” by the plan were never scheduled (this is the equivalent of the Final Adverse Determination for MLTC plans). About 75% of these appeals involve the plan’s denial of an increase in home care hours (personal care or CDPAP). The rest involve denial of one-time requests like medical supplies or equipment, or other issues.
To remedy this mistake, the State Dept. of Health has ordered this plan to give a “temporary approval” of the requested increase in hours now until the end of the current authorization or the next assessment, whichever is sooner. See letter sent by Healthfirst MAP to members. If at the next assessment the plan determines that a reduction is justified, it may reduce services. Advocates have asked DOH to confirm that the plan may only reduce services at the reassessment for reasons outlined in DOH MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services, and must provide advance notice of the proposed reduction with Aid Continuing rights.
Also, the plan must reimburse members who paid out of pocket for the requested increase in services after the adverse “Level 1” decision and prior to March 24, 2021.
In this article:
1. What are Medicaid Advantage Plus (MAP) plans and how are they different than regular MLTC plans?
There are two types of Medicaid managed care plans that provide Medicaid home care and other community-based long term care services for adult Dual Eligibles in NYS (Dual Eligibles = have Medicare and Medicaid)
Medicaid Advantage Plus (MAP) plans are “Fully Capitated” plans
These plans combine in one plan a certain kind of Medicare Advantage Plan, an MLTC plan and a Medicaid managed care plan. “Capitation” is the monthly premium a plan receives from the government to provide a package of services. “Full capitation” means that the plan receives a monthly “capitation” premium from both the federal and state government to provide ALL Medicare and Medicaid services.
See helpful info on ICAN website —What kinds of MLTC plans are there?
The plan is responsible for authorizing and paying for ALL Medicare and Medicaid services, including the services normally provided by an MLTC plan. The member must use only providers that are in the plan’s provider network. This is true for Medicare and Medicaid providers.
“DUAL FIDE SPECIAL NEEDS PLANS” – Only Medicare Advantage Plans that are “Dual-SNP’s” or DUAL-Special Needs Plans may become MAP plans. Further, it can’t be any Dual-SNP. It must be a Fully-Integrated Dual Eligible Special Seeds Plan (FIDE SNP). Some other Dual-SNPs are not fully integrated, meaning they may cater to people with Medicare and Medicaid but are not combined Medicare/Medicaid plans integrating both benefit packages. Download a list of all SNP’s in NYS to see which in your county are FIDE SNPs – only these can be MAP plans. A few are “HIDE” SNP’s – Highly Integrated SNPs. This list also has some SNP’s that are not D-SNPs – they are for I-SNPs for Institutionalized people or Chronic Care SNPs.
HOW MANY NEW YORKERS ARE IN MAP PLANS? And Where are the MAP Plans?
There are nearly 25,000 people in 10 MAP plans as of January 2021 – all but 800 of those are in NYC. See DOH monthly enrollment stats (Download document for most recent month — Tab named Medicaid Advantage Plus shows number enrolled in each plan in NYC and in each county).
Only 10 counties outside NYC have MAP plans as of January 2021.
Find lists of MAP Plans here.
ARE THERE OTHER “FULLY CAPITATED PLANS” LIKE MAP PLANS?
Yes. PACE plans are “fully capitated plans like MAP plans and also are only for people who need Medicaid long term care services, and the plans cover all Medicare and Medicaid services. Three are only 5,500 New Yorkers in PACE plans in NYC and 16 other counties as of January 2021 (See DOH monthly enrollment stats (download most recent document — On tab for Managed Long Term Care look at the TOP for PACE enrollment – number enrolled in each plan in NYC and in each county).
The FIDA program was similar to MAP, but was a demonstration program that closed at the end of 2019.
Managed Long Term Care (MLTC) or “Partially Capitated” plans
Most adults who have Medicare and need community-based long term care services are in “partially capitated” MLTC plans. This means the plan receives a monthly “capitation” premium payment from NYS only for the Medicaid long term care services in the MLTC benefit package. Members of MLTC plans have their Medicare coverage separate – they can choose to have Original Medicare or Medicare Advantage.
- If they choose Original Medicare, they may use any provider who accepts Medicare. There is no “provider network.”
- If they choose Medicare Advantage, they must use providers in their chose plan’s network. Some Medicare Advantage plans are Preferred Provider Organizations (PPO) and allow using providers out of network, usually at a higher out-of-pocket cost.
HOW MANY NEW YORKERS ARE IN MANAGED LONG TERM CARE PLANS?
In January 2021, there were 244,000 MLTC plan members in NYS, of which almost 194,000 are in New York City.
For a list of MAP plans in your area, go to https://www.nymedicaidchoice.com/choose/find-long-term-care-plan and enter your county or for lists of plans by area go to https://nymedicaidchoice.com/program-materials and scroll down to Long Term Care Plans in your area. Here is NYC:
WARNING – PLAN NAMES ARE CONFUSING!! Most MAP plans are operated by insurance companies that also operate MLTC partially capitated plans and other plans, such as Medicare Advantage plans. It can be difficult to tell one from the other. The lists at the links above show that they have slightly different names. When you ask your client what plan they are in, it is not enough to say “VNS CHOICE” since that company operates an MLTC (“VNS CHOICE”) and a MAP plan (“VNS CHOICE TOTAL”). All of these companies also operate Medicare Advantage plans.
MAP members who want to appeal an adverse decision by the MAP plan denying or reducing Medicaid personal care or CDPAP services (or any other plan services) must use a NEW appeal and hearing procedure that is slightly different than the regular OTDA Fair Hearings used for MLTC. In both MAP and MLTC, “exhaustion” of the plan appeal is required first before a fair hearing. See article on MLTC appeals and exhaustion.
The new Integrated Appeal process essentially continues the integrated procedure that was used in the FIDA demonstration program, that ended Dec. 31, 2019. OTDA calls it “FIDE-SNP” appeals – Fully Integrated Dual Eligible – Special Needs Plan.
How is the MAP-FIDE Appeal System Different than MLTC Appeals and Hearings?
Initial adverse notice (request for new or incresed service or notice of reduction) –
Plan Notice Denying Internal Plan Appeal –
Hearing – Two different hearing systems for MLTC and MAP –
MLTC – Member must request a Fair Hearing with NYS OTDA like any other Medicaid hearing. If the action is a threatened reduction, member must request the hearing in time to get Aid Continuing – before the Effective Date of the reduction.
MAP “FIDE” Hearings – are held by the Integrated Administrative Hearings Office (IAHO), which is administered by NYS OTDA through a separate system than regular Medicaid fair hearings. The procedures and timing requirements for the IAHO hearings are in the Memorandum of Understanding (MOU) between the NYS Dept. of Health and CMS that governs the integrated hearings demonstration.
Within 2 business days after its adverse Appeal Decision, the plan must AUTOMATICALLY forward the case and the case file to the IAHO, which serves as the request for the hearing. MOU Appendix 3, Section 184.108.40.206. The MAP member does NOT have to request this hearing.
Within 14 calendar days of forwarding the administrative record to the IAHO, the plan must send the member an Acknowledgement of Automatic Administrative Hearing and Confirmation of Aid Status with a copy to the IAHO. MOU Appendix 3, Section 3.4.4.; 3.5.1. The notice should advise the member that if the do not hear from OTDA about scheduling the hearing within 10 days (24 hours for expedited appeals), the member should call the IAHO.
OTDA is supposed to send the member and plan notice of the hearing 10 days in advance. MOU Appendix 3, Section 3.5.2.
EXTERNAL APPEAL – ALTERNATIVE to FAIR HEARING – or IN ADDITION TO HEARING – See info here.
MORE ABOUT MAP HEARING PROCEDURES
Mail: Integrated Appeals/IAHO-10A, P.O. Box 1930, Albany, NY 12201
- MLTC – FAX 518-473-6735 or
- Phone Contact to OTDA re Scheduling, Adjournments, Etc.
MAP: IAHO 1 (844) 523-8777
MLTC: OTDA OAH 1 (800) 342-3334
- Deadline for IAHO Decision – As in all Medicaid hearings, a final hearing decision must be made in 90 days from the hearing request (or plan’s automatic referral for the fair hearng). MOU Appendix 3 Sec. 3.6.1
- WARNING re Varshavsky case and Home Hearings: Members of regular MLTC plans have some special hearing rights under a class action called Varshavsky v. Perales. That decision held that Medicaid recipients who cannot travel to a hearing without substantial hardship because of a disability have the right to a hearing held in their home, if an initial hearing held by phone is not decided fully favorably. The State is taking the position that Varshavsky does not apply to MAP-FIDE hearings.
There are two important benefits of Varshavsky that as of now apply only to people in MLTC and not MAP plans. See Varshavsky fact sheet for more about these benefits.
- First, a decision after a phone hearing can only be issued if it is fully favorable. If it is not fully favorable, the decision cannot be issued, and the case must be scheduled for an in-home hearing.
- Second, even before COVID-19 there were long delays in scheduling home hearings, which must be held and decided within 90 days under the class injunction. Therefore, in any case where the appellant is classified as “homebound,” 45 days after the hearing was requested, NYS OTDA orders interim relief. If the issue of the hearing was denial of an increase in Medicaid personal care or CDPAP services, the interim relief, sometimes known as “Varshavsky Aid Continuing” requires the plan (or HRA/DSS if that’s who denied the increase) to temporarily increase the care to the amount requested, until the home hearing is held and decide. This interim relief is also ordered in the first situation above, where the “phone hearing” cannot be decided fully favorably, and the case is scheduled for an in-home hearing.
See Varshavsky Fact Sheet with more info and tips.
Both the MLTC FAD notice and the MAP-FIDE Plan Appeal Decision notice (in this zip file) explain that the member has the right to file an External Appeal with the NYS Dept. of Financial Services, which is NYS’s insurance department. External appeals may only be used if the denial was based on lack of medical necessity, but this is generally the issue in these appeals. The appeals are solely on paper so strong documentary evidence is needed.
If the “expedited” external appeal track is used, a decision may be issued in a matter of days – much faster than a fair hearing. If the external appeal decision is favorable, it is binding on the plan, and the fair hearing request may be withdrawn.
If the external appeal is decided adversely, the enrollee still may do the fair hearing. Since these take a long time to schedule, it is recommended to request the fair hearing first, then file and pursue the External Appeal while the Fair Hearing is pending.
Medicare Rights Center has created a toolkit with resources about MAP benefits, consumer rights and appeals. On that webpage you will find links to fliers:
FIDA (*transitioned 12/31/2019*) and NY Integrated Appeals and Grievances Demonstration
On January 1, 2020, CMS and NYSDOH transitioned remaining FIDA enrollees to MAP plans and aligned D-SNPs. This transition also included extending the FIDA integrated appeals and grievances process to MAP and aligned D-SNP plans. Under the revamped NY Integrated Appeals and Grievances Demonstration, CMS and NYSDOH are testing the integrated appeals and grievances process begun under FIDA with a larger volume of full benefit dual eligible individuals. As of January 2020, approximately 18,000 individuals are enrolled in a MAP and aligned D-SNP plan.