Instructions for Completing the Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP for the Integrated Benefits for Dually Eligible Enrollees (IB-Dual) Program

  • Instructions is also available in Portable Document Format (PDF)

NEW YORK STATE DEPARTMENT OF HEALTH, OFFICE OF HEALTH INSURANCE PROGRAMS

I. Overview

This guidance is applicable to Medicaid Managed Care Plans (MMCP), including Mainstream Managed Care Plans (MMC) and Health and Recovery Plans (HARP) that operate an Integrated Benefits for Dually Eligible Enrollees (IB-Dual) program. Specifically, this guidance applies to MMCPs operating the IB-Dual program where the aligned Dual Special Needs Plan (D-SNP) does not meet the Centers for Medicare and Medicaid Services (CMS) definition of an applicable integrated plan as defined in 42 C.F.R. § 422.561 (2019). This guidance ensures MMCP compliance with Federal and State Medicaid statutory and regulatory notice requirements when issuing the CMS-10003-NDMCP, also known as the Integrated Denial Notice (IDN), to IB-Dual enrollees after making an Organization Determination.

II. Applicability to Organization Determinations of Part B Drugs

This guidance is not applicable to denials or requests for payment of Part B drugs when the Part B drug is covered by Medicare and Medicaid, and the New York Medicaid Pharmacy Program (NYRx) is responsible for the Medicaid payment.

When NYRx is the responsible Medicaid payer, MMCPs must fill out the IDN with information relevant to the Medicare coverage decision only.

For additional information regarding MMCP responsibility for prescription drug coverage after the pharmacy transition to NYRx, please visit the NYRx website.

III. Instructions for IDN Completion

MMCPs must use the following instructions when issuing the IDN to IB-Dual enrollees after making an Organization Determination that denies (in whole or in part), reduces, suspends, or terminates a medical service, item, or Part B drug that is covered by both Medicare and Medicaid or a request for payment for a medical service, item or Part B drug that is covered by both Medicare and Medicaid.

  1. Section Titled: Your request was {Insert appropriate term: partially approved, denied}
    1. MMCPs must follow CMS’ instructions provided for this section in the Form Instructions for the Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP, except that this section should be filled out with information relevant to the Medicare decision only.
  2. Section Titled: Why did we deny your request?
    1. MMCPs must follow CMS’ instructions provided for this section in the Form Instructions for the Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP, except that this section should be filled out with information relevant to the Medicare decision only.
      1. When the MMCP denies, partially approves, reduces, suspends, or terminates the service under both Medicare and Medicaid, the MMCP must include a statement in the free text field of this section informing the enrollee that the service/item or Part B drug or Medicaid drug was also denied, partially approved, reduced, suspended, or terminated under the enrollee’s Medicaid benefits and reference the enclosed Medicaid Initial Adverse Determination Notice.
      2. When the MMCP denies, partially approves, reduces, suspends, or terminates the service under Medicare but approves the service under Medicaid, the MMCP must include a statement in the free text field of this section informing the enrollee that the service/item or Part B drug or Medicaid drug will be covered under the enrollee’s Medicaid benefits and reference the enclosed Medicaid Approval Notice.
  3. Section Titled: You have the right to appeal our decision
    1. When the MMCP denies, partially approves, reduces, suspends, or terminates the service under both Medicare and Medicaid, the MMCP must insert the following text in the brackets provided for Medicaid information (Brackets state: [Insert Medicaid information explaining plan level appeal must be exhausted prior to requesting State Fair Hearing or other state external review.]).

      Because our decision is about a service covered by both Medicare and Medicaid, you can ask for a Plan Appeal through Medicare or Medicaid or both. A Medicaid Plan Appeal offers you different appeal rights than a Medicare Plan Appeal. The Medicaid Plan Appeal process includes the right to a State Fair Hearing, and in some cases the right to a New York State External Appeal.

      [{Insert as applicable for determinations to reduce, suspend, or stop services}

      If you want to keep your services the same

      • You must ask for a Medicaid Plan Appeal within 10 calendar days or by the date this decision takes effect, whichever is later.
      • The last day to ask for a Medicaid Plan Appeal and keep your services the same is [date+10].
      • Your services will stay the same until we make our decision. Your provider must agree that you should continue getting the service. If the Medicaid Plan Appeal is not decided in your favor, you may have to pay for the services you got while waiting for the decision.]

      You have 60 days from the date of this notice to ask for a Plan Appeal through Medicare or Medicaid, or both.

      If you do not tell us what kind of appeal you want, we will process your appeal as a Medicaid Plan Appeal.

      To learn about the Medicaid Plan Appeal process, see the enclosed Medicaid Initial Adverse Determination Notice.

      The Medicare Plan Appeal process is explained here:

    2. The MMCP should not insert the following Medicaid text provided by CMS in the Plan Appeal section:

      [How to keep your services while we review your case: If we’re stopping or reducing a service, you can keep getting the service while your case is being reviewed. If you want the service to continue, you must ask for an appeal within 10 days of the date of this notice or before the service is stopped or reduced, whichever is later. Your provider must agree that you should continue getting the service. If you lose your appeal, you may have to pay for these services.]
  4. Section Titled: There are 2 kinds of appeals with {health plan name}
    1. The MMCP should not insert Medicaid decision timeframes in the Standard Appeal or Fast Appeal areas.
  5. Section Titled: How to ask for an appeal with {health plan name}
    1. The MMCP should not insert the Medicaid text provided by CMS at the end of the Step 1: section.
  6. Section Titled: What happens next?
    1. The MMCP should not insert State specific Medicaid rules in this section.
  7. Section Titled: How to ask for a Medicaid State Fair Hearing?
    1. The MMCP should not insert the Fair Hearing text provided by CMS in this section.
  8. Section Titled: Get help & more information
    1. The MMCP must insert the following text:

For Medicaid Managed Care issues, contact the New York State Department of Health Bureau of Consumer Services by emailing ManagedCareComplaint@health.ny.gov or calling 1-800-206-8125 to file a complaint.

IV. NYS Department of Health Medicaid Managed Care Model Template Notices

The MMCP must use the appropriate Medicaid Managed Care model template notice to advise the IB- dual enrollee of the Medicaid decision and appeal rights.

  1. When the MMCP denies, partially approves, reduces, suspends, or terminates the service under both Medicare and Medicaid, the MMCP must enclose the applicable Medicaid Initial Adverse Determination Notice along with the Notice of Denial of Medical Coverage (or Payment) CMS- 10003-NDMCP.
  2. When the MMCP denies, partially approves, reduces, suspends, or terminates the service under Medicare but approves the service under Medicaid, the MMCP must enclose the Medicaid Approval Notice with the Notice of Denial of Medical Coverage (or Payment) CMS-10003-NDMCP.

V. Implementation of IDN Letters

MMCPs are not required to submit template IDN letters to the Department prior to use.

6/27/2024