New Appeals Process for MLTC Members Goes into Effect May 1, 2018

Starting May 1, managed long-term care (MLTC) members must follow new appeals procedures. While the Obama Administration adopted these procedures, they have only now gone into effect. MLTC members should pay close attention to the changes so that they preserve their appellate rights.

The Old Rule

Before May 1, MLTC members had appeal options whenever their plan denied a request for services, reduced a service, or stopped a service. According to the old rule, members could:

• File an internal appeal with the MLTC and, if they lost the appeal, they could request an External Appeal or a Fair Hearing.
• Alternately, they could go directly to a Fair Hearing.

Under the old rule, if the plan decided to stop or reduce a service, you had to immediately request a Fair Hearing if you wanted to get Aid Continuing.

The New Rule (After May 1, 2018)

The new rule no longer gives MLTC members the option of going directly to a Fair Hearing. Instead, all members must appeal internally to their MLTC. Only after receiving a Final Adverse Determination (FAD) can the member request a Fair Hearing.

If you want Aid Continuing, you still must file an internal appeal. However, the new rule only gives you 10 days from the notice to be entitled to Aid Continuing. In other situations, you get 60 calendar days to file your appeal (but you should file as soon as possible).

These new rules apply to appeals, not grievances or complaints. Appeals relate to the plan’s decision to stop or reduce services or to not provide services. By contrast, a grievance relates to the quality of care you receive, such as a tardy or poorly trained aide.

Requesting the Internal Appeal

You have several options for requesting an internal appeal:

• You can call your plan’s phone number. Follow up your oral request with a letter unless you want a Fast Track appeal.
• You can fax your request. The notice you receive should contain the fax number. Use the form provided with the notice.
• You can email your request. Attach your appeal request form to the body of the email.
• You can also submit a written request to your plan. Write “Appeal Request” on the outside front of the envelope, as well as on the letter. Your letter should include your name, address, Member I.D., Medicaid number, and phone number. Also, you should explain the reason for your appeal. Mail the letter certified mail, return receipt requested.

The law requires that your MLTC plan provider help you file an appeal. For example, you might need translation services to file your appeal properly.

Call Us Today to Speak with a Elder Law Attorney in New York

Managed care appeals are quite complicated—not to mention critical to the health or well-being of you or a loved one. At Goldfarb Abrandt & Salzman LLP, our senior law attorneys have worked with countless clients to secure them access to the medical treatments and care that they require. However, every situation is different and past successes are no guarantee of future results. If you have a question about appealing a managed care denial, please contact us today. Reach us by phone at (212) 387-8400 or by submitting our contact form.