DOH Provides Details of New Managed Care Appeals, Fair Hearing, and "Aid Continuing" Procedures
The Department of Health (DOH) provided additional detail about new managed care appeals, fair hearing, and "aid continuing" procedures in an April 13th webinar. The new procedures are required by federal regulations and take effect on May 1, 2018. They apply to partially-capitated managed long term care (MLTC) plans, Medicaid Advantage Plus (MAP) plans, mainstream Medicaid Managed Care plans, Health and Recovery Plans (HARPs), and HIV Special Needs Plans (SNPs). They do not apply to Programs of All-Inclusive Care for the Elderly (PACE) or Fully-Integrated Duals Advantage (FIDA) plans.
Responding to questions raised in a prior webinar, the April 13th presentation focused principally on the requirement to exhaust internal managed care plan appeal processes prior to requesting a fair hearing and on procedures for seeking a continuation of services during the pendency of the appeal and fair hearing processes (known as "aid continuing"). Under the new regulations, enrollees must generally exhaust or be "deemed" to have exhausted the managed care plan's internal appeal process in order to request a fair hearing. An enrollee is deemed to have exhausted the internal appeal process if the plan fails to comply with regulatory requirements governing the provision of notice of its actions within specified timeframes or fails to make a determination on an appeal by the regulatory deadline. These new requirements apply to denials and reductions of services on or after May 1st. However, if a plan issues an initial adverse determination after May 1st and the enrollee requests a fair hearing without first exhausting the internal appeal process, the Office of Administrative Hearings may still grant the fair hearing request.
The enrollee's right to a continuation of previously authorized services is preserved under the new regulations if the enrollee appeals or requests a fair hearing within 10 days of the initial or final adverse determination or by the effective date of the decision, whichever is later, and does not opt out of "aid continuing." If the plan ultimately prevails, the enrollee may be liable for the costs of services received during the pendency of the appeal and/or fair hearing. Providers are not permitted to request aid continuing – if the provider submits an appeal on behalf of an enrollee, the plan must ask the enrollee if he/she wishes to continue services at the same level.
The webinar also included detailed information about the requirement imposed on plans to provide case files free of charge to enrollees and their representatives when a decision is appealed or a fair hearing is requested and to provide the evidence packet in advance of fair hearings.
More information, including frequently asked questions, is available here, here, and here. The webinar slides are available here.
Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124