Changes in Fair Hearing Rights for Medicaid Managed Long Term Care and Managed Care Members Effective May 2018

by David Goldfarb

Starting on May 1, 2018, Medicaid subscribers in New York state will see drastic changes to their appeals process. These changes place more procedural requirements on those seeking to appeal Medicaid determinations.

An experienced New York elder law attorney can help Medicaid subscribers who need assistance with their Medicaid appeals. For decades, the elder law attorneys at Goldfarb Abrandt Salzman & Kutzin have helped New Yorkers file and pursue effective Medicaid appeals.

Learn more about the new procedural requirements, and your right to challenge adverse Medicare decisions, by reading on.

The Changes

For many Medicaid subscribers, the new “exhaustion” requirement will form the biggest change to the appeals process. Currently, subscribers can request a fair hearing without submitting to an internal review of the claim. After April 2018, however, they will have to both exhaust the plan’s internal review procedure and receive an adverse appeal determination before they may file a request for fair hearing. This is due to changes in the Code of Federal Regulations enacted by the Obama Administration.

There is a small exception to this exhaustion requirement. If the plan fails to meet notice or timing requirements, the subscriber is “deemed exhausted” of the internal review process. This creates a legal presumption that the internal appeals process was exhausted, and the subscriber is now entitled to request a fair hearing.

This requirement presents many practical challenges for recipients of Medicaid services. For example, if the plan sends notice that it intends to reduce home care service hours, or stop or reduce any other service, the member must request an internal plan review within ten days to prevent service reduction or stops while appealing the claim.

But requesting an internal plan review can prove far more difficult than requesting a fair hearing. Unlike the dedicated phone line for fair hearing requests, internal appeals are routed through a general 800 number that handles all plan issues. Internal appeals also do not use the online submission option available for fair hearing requests. Also, Medicaid plans need only mail notice of reductions or termination of services ten days before they intend to enact such changes. Mailing time, holidays, or weekends may leave a subscriber with only one or two working days in which to place a call to the plan and request the internal review.

These and many other practical challenges are likely to arise as a result of the new internal review exhaustion requirement. A New York elder law attorney, however, can help subscribers meet these requirements and launch effective substantive challenges to denials of their claims.

Protect Your Medical Coverage With the Counsel of a New York Elder Law Attorney

Don’t leave your health care to chance. Consult with an attorney to ensure that you are on all applicable plans that are available to you, your claims are not denied, and you have the full extent of coverage to which you are entitled. The elder law attorneys at Goldfarb Abrandt Salzman & Kutzin have decades of experience in ensuring that benefits are made available to those who deserve them. Call (212) 387-8400 or write to us today to schedule your consultation.