New Rules for Appeals and Fair Hearing Rights Effective May 1

What is changing on May 1, 2018?

What is changing on May 1, 2018?

New federal Medicaid managed care rules take effect in New York State. These rules change the way Medicaid managed care plans make decisions about health care services and Plan Appeals.

These rules change how you can ask the State for a Fair Hearing about plan decisions.  Starting May 1, 2018, if you think a plan decision is wrong, you must first ask for a Plan Appeal before asking for a Fair Hearing. If your care is changing, and you want to keep your services the same while your case is reviewed, you must first ask for a Plan Appeal before asking for a Fair Hearing.          

How does this change affect me?

For some services, you have to ask the plan for approval before you get them. This change means that the plan will make some of these approval decisions faster than they did before. If you think your plan’s decision about your health care is wrong, you can ask the plan to look at your case again. This is called a Plan Appeal. This change means you must first ask for Plan Appeal before you ask for a Fair Hearing. You will have 60 days to ask for a Plan Appeal.

What if the plan’s decision is changing a service I am getting now?

If you want to keep your services the same, this change means you must first ask for a Plan Appeal within 10 days or by the date the decision takes effect, whichever is later. Your services will stay the same until there is a decision. If you lose your Plan Appeal, you may have to pay for the services you got while waiting for the decision.

Can someone ask for a Plan Appeal for me?

If you want someone, like your provider, to ask for the Plan Appeal for you, this change means you and that person must sign and date a statement saying this is what you want.

What happens after I ask for a Plan Appeal?

After you ask for a Plan Appeal, this change means the plan will send you your case file, with all the information they have about your request. The plan will then send you their decision about your appeal. This change means if you do not receive a response to your Plan Appeal or the decision is late, you can ask for a Fair Hearing without waiting for the plan’s decision.

What if I think the Plan Appeal decision is still wrong?

If you think the plan’s decision about your appeal is wrong, you can ask for Fair Hearing. You will have 120 days to ask for Fair Hearing. If the plan said the service is not medically necessary, you can still ask the State for an External Appeal. You will have four months to ask for an External Appeal. If you ask for both, the Fair Hearing decision will always be the final answer.

If the plan is changing care you are getting right now, and you want your services to stay the same, you must ask for a Fair Hearing within 10 calendar days from the appeal decision or by the date the appeal decision takes effect, whichever is later. Your services will stay the same until the fair hearing decision. If you lose your Fair Hearing you may have to pay for services you got while waiting for the decision.

How long can the plan take to decide?

If you request approval for a service, your plan has 14 days to make a decision. If your health is at risk, your plan must fast track your request and decide in 72 hours. The decision may take longer if the plan needs more information. If your plan covers prescription drugs, the plan must make decisions about your prescriptions in 24 hours.

If you ask for a Plan Appeal, the plan has 30 days to make a decision. If your health is at risk, your plan must fast track your appeal and decide in 72 hours. The decision may take longer if the plan needs more information.

Where can I get more information?

Call member services at 1.877.ICS.2525, TTY: 711. See your member handbook for full information about your appeal rights.

You can call the Independent Consumer Advocacy Network (ICAN) to get free, independent advice about your coverage, complaints, and appeals’ options. They can help you manage the appeal process. Contact ICAN to learn more about their services:


Phone
: 1-844-614-8800 (TTY Relay Service: 711)

Web: www.icannys.org | Email: ican@cssny.org

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