Medicaid Managed Care Appeals Changes Coming
The Department of Health (DOH) has scheduled two webinars to review new requirements for Medicaid Managed Care service authorization requests, appeals, and complaints. The changes stem from the federal Medicaid and Children's Health Insurance (CHIP) Programs Final Rule published on May 6, 2016, amending federal rules at 42 CFR Part 438, and impact Single Capitated MLTC plans and Medicaid Advantage Plus plans as well as mainstream Medicaid Managed Care.
Starting May 1, 2018, plans will be required to complete reviews of service authorization requests under different time frames, issue revised enrollee notices, and, for adverse determinations made on May 1, 2018 and thereafter, follow revised appeal processes. Starting in May, enrollees wishing to dispute a plan's adverse determination regarding their services must exhaust the plan's internal appeal process before requesting a fair hearing. The enrollee will be able to have their services continue from the plan upon filing a plan appeal within 10 days of the Initial Adverse Determination notice or before the effective date of the decision, whichever is later. If the plan upholds its decision and issues a Final Adverse Determination, the enrollee may have their aid continue by requesting a State Fair Hearing within a specified time frame. If the enrollee loses their plan appeal or fair hearing, they may have to pay for the services they received while their appeal/fair hearing was being decided.
The webinar presentation is aimed at providers, community representatives, and enrollees; requires no advance registration; and will be archived for on-demand viewing. Access information for each two-hour webinar (that will provide the same information) is as follows:
March 28, 2018, 1 to 3 PM
- Click here to join the webinar
- Dial in using 844-633-8697 or 518-549-0500 and enter access code 646 221 892
March 30, 2018, 10 AM to 12 PM
- Click here to join the webinar
- Dial in using 844-633-8697 or 518-549-0500 and enter access code 645 278 217
The full DOH webinar announcement is available here.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841