DOH Webinar Describes Changes in Managed Care Authorization, Appeals, and Fair Hearing Procedures

The Department of Health (DOH) presented a webinar last week on changes in managed care authorization, appeals, and fair hearing procedures. The new procedures arise out of changes in federal regulations and apply to partially-capitated managed long term care (MLTC) plans and Medicaid Advantage Plus (MAP) plans, as well as mainstream Medicaid Managed Care. Beginning May 1, 2018, the following changes will apply to authorization requests, appeals, and fair hearings:

Managed care plans must address urgent or “fast track” requests for authorization of a service within 72 hours of receipt. An authorization request is considered urgent if the member’s health is at risk. Under current regulations, these requests must be addressed within three business days.
Before seeking a fair hearing in response to an adverse determination, managed care plan members must pursue an internal plan appeal.
The member has 60 days from the date of the initial adverse determination to request an internal appeal. However, in order to continue an existing service or level of service until a decision is rendered, the enrollee must appeal the determination within 10 days of the receipt of the initial adverse determination or the effective date of the determination, whichever is later.
In order to appoint someone to appeal a decision or file a complaint on his/her behalf, the member must submit a written authorization. This applies to appeals and complaints submitted by providers as well as family members.
When a member appeals an adverse determination, the managed care plan must send the member his/her case file.
If an appeal is urgent (i.e., the member’s health is at risk), the process is “fast tracked,” and a decision must be made within 72 hours of the receipt of the appeal. If the plan needs additional information to make an informed decision, it may take up to 14 days to make a decision, provided that the delay is in the best interests of the member.
If the plan does not agree to reverse the initial adverse determination, the final adverse determination notice must include information about fair hearing rights.
The member may ask for a fair hearing after receiving a final adverse determination or after the time allotted for an internal appeal decision has elapsed. The member has 120 days from the final adverse determination to request a fair hearing. However, he/she must request a fair hearing within 10 days of an adverse determination in order to continue an existing service until a fair hearing decision is rendered.
If the member wins at a fair hearing, the plan must provide or authorize the requested service within 72 hours of the decision, or sooner if the member’s health requires it.

The federal regulations also modify procedures for managed care complaints or grievances. A grievance relates to the quality of care, services, or treatment a member receives from the plan, rather than the scope, amount, or type of services approved by the plan. Under the new regulations:

In order to appoint someone to file a complaint on his/her behalf, the member must provide a written authorization.
If the complaint is urgent, the plan must respond within 72 hours of receipt of all necessary information and no later than seven days after receiving the complaint.
If the complaint is not urgent, the plan must respond within 45 days of receiving all necessary information and no later than 60 days from receiving the complaint.

A recording of the webinar will be made available on the DOH website; the slides are available here. The webinar included extensive questions and answers, and the Department has indicated that it will publish additional written “Frequently Asked Questions.” Questions may be submitted here. LeadingAge NY will provide a link to the slides and recording within this article as soon as the materials are posted. Additional information is available here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124