Changes are Coming to MLTC Appeals!

If you or a loved one suffer from a disability or chronic illness, you may be under a managed care regimen, such as a Medicaid managed plan or a plan for managed long-term care (MLTC) in New York. State officials recently announced significant changes coming to the way they handle MLTC and managed care plan appeals.

What you need to know

In the past, if an MLTC plan, Medicaid managed care plan or HARP plan stopped providing a service, patients could directly appeal to the State of New York for a Fair Hearing if they believed the stoppage of services occurred in error.

Beginning on May 1, 2018, however, patients subjected to these plans must first appeal directly to their plan provider if a service is stopped. This action—called a Plan Appeal—will ask the plan provider—often an MLTC company—to examine the case. Only after the plan provider issues a decision can you appeal to the state for a Fair Hearing!

Under the new rules, MLTC companies must issue a notice informing patients of service termination at least 10 days prior to the service ending. Patients have just 10 days to respond to the notice if they want to maintain their services while the company’s determination is appealed.

If patients don’t file an appeal within 10 days, they have a total of 60 days to file a Plan Appeal with the MLTC company. At the end of the 60-day window, patients can no longer appeal the company’s decision to stop providing services.

How this applies to you

Due to the complex nature of MLTC and Medicaid managed care plan laws, it can be challenging to determine exactly what these changes mean for every day patients. Remember, these changes will only affect you if your MLTC provider decides to stop providing one of the services you rely on.

If this is the case, it’s important to remember that you have to appeal directly to the MLTC company, using the Plan Appeal mechanism. If you attempt to bring your case to the state for a Fair Hearing, you may end up wasting the time you have to appeal the case, thus losing your right to fight the service cessation.

Unscrupulous MLTC providers may not provide patients with the proper notification of the new MLTC rules, causing them to exhaust the entirety of their 60-day appeal window.

If you receive managed care in New York and want to learn more about your rights as a patient or guardian, consult with The Law Office of Antony M. Eminowicz, PLLC. We’ll keep your best interests in mind as we help you navigate this critical change to MLTC care.

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