This article can also be downloaded as a Fact Sheet here.
If you received Medicaid personal care or Consumer-Directed Personal Assistance (CDPAP) services, and then you were required to enroll in or transfer to a different Managed Long Term Care plan, your new Plan must continue to authorize the same amount and type of home care services you received in your previous plan, or that you received from your local Medicaid agency. This is known as your right to “continuity of care” or “transition” rights.
But this is only required for a limited amount of time. The new Plan is permitted to review your case and even attempt to cut your hours after the transition period. It is likely you can successfully challenge any attempts to reduce services, but it is necessary for you to be prepared for this process so that you can protect your services.
This fact sheet explains:
A. What are Continuity of Care or Transition Rights and how long do they last?
E. Get Help
Download this article as a fact sheet here.
A. What are continuity of care rights?
Transition or continuity of care rights mean that your Managed Long Term Care [“MLTC”] plan must give you the same type and amount of Medicaid services that you received before you enrolled in your current plan. Transition rights are required in all types of Medicaid managed care plans. This article focuses on MLTC, Medicaid Advantage Plus (MAP) and PACE plans.
How Long is the “Continuity of Care Period” or “Transition Period?”
Your MLTC plan must continue the same services with the same hours for 90 days, with one exception: the Transition Period is 120 days if you switched to a different plan because your old MLTC plan closed.
Transition rights are granted when one of FOUR events has occurred, because the law requires you to join a specific type of managed care plan, as follows:
- You received personal care or CDPAP from your local Medicaid office, such as through the Immediate Need program, for more than 120 days. (See Fact Sheet on Immediate need). After 120 days of receiving services from the local Medicaid office, you will likely receive a notice from NY Medicaid Choice telling you to select an MLTC plan. The notice will give you a choice of plans. If you don’t pick a plan, you will be assigned to an MLTC plan (the most common type of plan; less common types are Medicaid Advantage Plus (MAP) or PACE plans). The MLTC plan must continue the same home care hours for a 90-day Transition Period. See contacts at the end of this fact sheet for advice on choosing a plan, and/or to see if you do not have to enroll in an MLTC plan because you qualify for an exemption.
- You received Medicaid home care from a Medicaid managed care plan designed for people without Medicare, and you are now Medicare eligible – If you do not have Medicare you may have been enrolled in a mainstream Medicaid managed care health plan, which provides all Medicaid services including personal care, CDPAP, and private duty nursing. If you received home care from your Medicaid health plan, and then you enroll in Medicare, you are required to enroll in an MLTC or MAP plan. The MLTC or MAP plan must continue the same plan of care for a 90-Day Transition Period.
- If your MLTC plan closes or stops providing service in the county that you live in, you must transfer to a new plan. The new plan must continue the same services and hours for a Transition Period of 120 days, not 90 days.
- If you are involuntarily disenrolled from one MLTC or MAP plan, and assigned to another plan, the new plan must continue the same plan of care for 90 days. Involuntary disenrollments were banned for most of the pandemic. However, as of fall 2021 NYS is again allowing such disenrollments to resume on four grounds.
In all cases of involuntary disenrollment the plan must send you a 30-day notice of the planned disenrollment, followed by a 10-day notice from NY Medicaid Choice, which states your right to request a Fair hearing. Many members will be reassigned to a different MLTC plan after they are disenrolled. They have transition rights in that plan.
Involuntary disenrollments were suspended during the COVID pandemic, but NYS DOH is allowing plans to disenroll members again on the following grounds. Others may resume in 2022.
- You are a Medicaid Advantage Plus (MAP) plan member, but you enroll in a new Medicare Part D drug plan or Medicare Advantage plan – MAP plans combine in one all-in-one plan a “DUAL-SNP” Medicare Advantage Special Needs Plan for Dual Eligibles, plus an MLTC plan. MAP plans cover all Medicare, Medicaid, home care, and pharmacy benefits in one insurance plan. If you are a MAP member and you change Medicare coverage, such as by selecting a new Part D drug plan, you will be disenrolled from your MAP plan. This is because you are no longer in the DUAL-SNP that provides the Medicare services in your MAP plan. See more about MAP plans here. Since April 2021, some Medicaid recipients are “default enrolled” in these plans when they first became enrolled in Medicare, so might not realize they are in a MAP plan. See this article.
- You move to a different county in NYS that is out of the MLTC plan’s service area. Most MLTC plans only serve certain counties. If you move to a county that is not served by your plan, and notify your local Medicaid office (HRA in NYC) of the change of address, you will be disenrolled from your old MLTC plan.
- You or your family member’s behavior impairs plan’s ability to provide services (disenrollments begin Jan. 1, 2022) for MAP, PACE & MLTC. See GIS 21 MA/24 (plan must submit names of home care agencies used and results of service attempts; member reassigned to new MLTC plan if disenrolled).
- You were absent from the service area for more than 30 consecutive days (90 days for Wellcare Fidelis Dual Plus MAP only). (disenrollments begin Jan. 1, 2022). See GIS 21 MA/24. Plan must submit form to NY Medicaid Choice stating last date of contact with enrollee. Member notified that they may transfer to a different MLTC plan. If no response from member, member disenrolled to local district which must continue same plan of care until they reassess.
As background, MLTC plans may generally reduce your hours of home care services only for reasons allowed by state regulations. The reasons a plan may reduce hours are stated in a State policy MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care or CDPAP Services. A plan is allowed to reduce your hours only if your medical condition improved, your social circumstances changed, or in very limited situations, if a mistake was made in the earlier authorization. The plan must show that this change reduces your need for home care.
Before Nov. 8, 2021 – The same MLTC Policy 16.06 that restricts a plan’s ability to reduce your hours generally also applied after a Transition Period ended. A plan could reduce your hours after the Transition Period ended only if they could prove that a major change in your condition or circumstances occurred since your hours were previously authorized by your old plan or by the Medicaid office if you received Immediate Need home care. The new Plan would have to explain why this change reduces your need for home care.
After Nov. 8, 2021 – A change in a state regulation allows MLTC plans to reduce your hours after the Transition Period if the Plan determines that the previous plan or Medicaid agency gave you “more services than are medically necessary,” without proving any change. The Plan’s notice proposing to reduce your services need only “indicate a clinical rationale that shows review of the client’s specific clinical data and medical condition.” The Plan no longer has to prove that you need less home care for one of the reasons in MLTC Policy 16.06.
What has NOT changed- If your new plan wants to reduce or end services after the Transition Period, the plan must still give you:
- A letter called an “Initial Adverse Determination” notice at least 10 days before reducing services. If you request a Plan Appeal before the effective date of the reduction, your services will not be reduced while the appeal is pending (this is known as “Aid Continuing”). But this does not mean your fight is over. Seek help from the resources listed below.
- If you lose your appeal, the Plan should send you a “Final Adverse Determination” letter at least 10 days before the reduction takes effect. If you request a Fair Hearing before the effective date, you will have Aid Continuing, so your services will not be reduced while the fair hearing is pending. Seek help from the resources listed below.
Remember: These new rules only allow a plan to reduce hours more freely after a Transition Period ends. Any other reductions in hours must be for one of the reasons stated in MLTC Policy 16.06
See more about MLTC Appeals and Hearings here.
- If you receive an Initial Adverse Determination (PDF) request a PLAN APPEAL right away to get Aid Continuing.
- If you receive a Final Adverse Determination (PDF) —request a Fair Hearing right away to get Aid Continuing.
- After you make these requests, if you want help in the appeal or hearing, get help from organizations listed below.
- In the plan appeal or fair hearing, say that the new Plan has the burden of proof of producing the previous records from the Local Medicaid office or previous plan. These records should be necessary at both levels of appeal for the Plan to prove that you receive more hours than medically necessary; the Plan should not be able to reduce services without producing these records.
- Consumers receiving Immediate Need services from the Local Medicaid office should ask their Medicaid office for their complete home care file. Those receiving home care from a mainstream managed care health plan and become enrolled in Medicare should ask the health plan for their home care file. This may be useful later to refute a new plan’s claim that the hours authorized previously were not medically necessary.
- Despite the change in the regulations, advocates believe that due process still forbids plans from reducing hours unless there was a change since the hours were first authorized. Changes could be that the consumer’s medical condition improved, social circumstances changed, or a mistake was made in the previous assessment. See note 8 and MLTC Policy 16.06Consumers should raise this argument in all appeals and fair hearings and get help, below.
Statewide – ICAN – Independent Consumer Assistance Network – Ombudsprogram for MLTC
firstname.lastname@example.org TTY: 711 Website: icannys.org (844) 614-8800
New York City —
- CSS – Community Health Advocates (888) 614-5500
- New York Legal Assistance Group (NYC) –
General intake (212) 613-5000
Evelyn Frank Legal Resources Prog. (Mon. 10 AM -2 PM) (212) 613-7310
- The Legal Aid Society (NYC) (888) 663-6880
- JASA/ Queens Legal Services for Elder Justice (Queens only) (718) 286-1500
- Legal Services NYC (citywide) (M – F 10 AM – 4 PM) (917) 661-4500
Outside NYC –
- ICAN (844) 614-8800
- Empire Justice Center Health@empirejustice.org (800) 724-0490 x 5822
- Center for Elder Law & Justice (716) 853-3087
Serves 10 counties in western NY: Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Livingston, Niagara, Orleans, Steuben, Wyoming
This article prepared by NYLAG Evelyn Frank Legal Resources Program 12/8/2021 email@example.com
Fact sheet posted at http://www.wnylc.com/health/download/797/
Check here for updates!
 Transition rights when transitioning from “fee for service” to managed care and when involuntarily disenrolled from a plan are required by 42 C.F.R. § 438.62 and the CMS Special Terms & Conditions. See CMS Special Terms & Conditions (Aug 2020) (Section V(4)(g) at pp. 32-33). See more about the Immediate Need program at http://www.wnylc.com/health/entry/203/
 See MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC. During the pandemic, however, many consumers have just stayed in their Medicaid managed care plans, which continue to provide their home care. Eventually they will be required to enroll in an MLTC plan. Even during the pandemic, some members of Medicaid managed care plans who are new to Medicare have been transitioned to Medicaid Advantage Plus (MAP) or MLTC plans under “Default Enrollment,” unless they opted out. See this article.
 18 NYCRR Sec. 505.14(b)(4)(viii)(c)(3)(vii), 505.28(i)(4)(iii)(h) as amended eff. 11/8/21 (posted here – at pp. 60 and 137). NYLAG, along with the NYSBA and other organizations submitted extensive comments opposing these and other changes in the regulations. See Point 11, pp. 29-32 of NYLAG comments. NOTE: Most other changes in the state regulations will not go into effect until 2022 or later, even though the official effective date is Nov. 8, 2021. This includes new restrictions on eligibility for personal care or CDPAP and new “Independent Assessor” procedures described here. See DOH summary of which changes go into effect on Nov. 8th, 2021 (Recording) – (PDF) and new NYS DOH Independent Assessor webpage.
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.