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

  • Guidance also available in Portable Document Format (PDF)

Guidance for Applicable Integrated Plans on State Written Notice Requirements for Integrated Determinations

I. Overview

This guidance is applicable to Medicaid Advantage Plus (MAP) Plans, Mainstream Managed Care Plans (MMC), and Health and Recovery Plans (HARP) that operate the Integrated Benefits for Dually Eligible Enrollees (IB-Dual) Program, collectively referred to here as Medicaid Managed Care Plans (MMCP). Specifically, this guidance applies to MMCP who provide coverage of Medicare services for dually eligible enrollees through an aligned Medicare Advantage (MA) Dual Special Needs Plan (D-SNP) that meets the Centers for Medicare and Medicaid Services (CMS) definition of an Applicable Integrated Plan (AIP), as defined in 42 C.F.R. §422.561. This guidance ensures MMCP compliance with state statutory and regulatory written notice requirements for integrated determinations regarding Medicaid covered services and Medicaid related complaints. This guidance does not apply to determinations regarding Medicare-only covered services or Medicare related complaints. For the purposes of this guidance, the term “dually eligible enrollee” shall mean a MAP enrollee or IB-Dual enrollee in a MMCP aligned with an AIP D-SNP.

This guidance is effective 2/13/2026.

II. Background

The Bipartisan Budget Act (BBA) of 2018 and subsequent CMS final rules require all D-SNPs that meet CMS’ definition of an AIP (i.e. a D-SNP with exclusively aligned enrollment), and their aligned MMCP, utilize unified appeals and grievance processes to further integrate Medicare and Medicaid for their dually eligible enrollees. In accordance with the BBA, Medicare Advantage Federal Regulations at 42 C.F.R. Part 422, CMS’ Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidanceissued on November 22nd, 2024, and the Addendum to the Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance issued on January 1st, 2025, CMS has provided model letters for AIPs to utilize when noticing dually eligible enrollees of certain integrated determinations. CMS does not require written notice of favorable integrated organization determinations, integrated reconsiderations, or of integrated grievance determinations that were filed verbally; nor does CMS provide a model letter to be used for these situations. However, MMCP are still required by New York State statute and regulations to provide written notice. The Department of Health (the Department) is requiring MMCP to utilize Medicaid model notices to meet the State’s written notice requirements for these determinations.

III. Department Medicaid Model Notices Required for Certain Integrated Determinations

The following Department Medicaid model notices must be sent to dually eligible enrollees, as outlined below, to ensure compliance with New York State Public Health Law §4408-a, New York State Public Health Law Article 49, and 10 NYCRR 98-1.14(e).

  1. Approval Notice
    1. MMCP must utilize the Department’s Medicaid model Approval Notice to provide written notice to a dually eligible enrollee of a favorable integrated organization determination or integrated reconsideration regarding Medicaid covered services.
  2. Complaint Resolution Notice
    1. MMCP must utilize the Department’s Medicaid model Complaint Resolution Notice for the purpose of providing written notice to a dually eligible enrollee of an integrated grievance determination for issues related to Medicaid.
    2. For the purpose of this guidance, an integrated grievance shall be referred to as a “complaint”, which shall mean any issue of dissatisfaction with the MMCP operations, other than those grievances identified in §4408-a of the Public Health Law.
    3. Complaints shall include, but are not limited to:
      1. the quality of care or services provided;
      2. aspects of interpersonal relationships such as rudeness of a provider or employee;
      3. a dispute regarding the extension of time proposed by the MMCP to make an integrated organization determination or integrated reconsideration;
      4. a dispute of the MMCP’s refusal to grant an expedited integrated organization determination or expedited integrated reconsideration; and
      5. failure to respect the dually eligible enrollee's rights regardless of whether remedial action is requested.
    4. Complaints shall not include complaints submitted to a Medicare Quality Improvement Organization (QIO) in regard to the quality of services a dually eligible enrollee has received.
  3. Complaint Appeal Resolution Notice
    1. Consistent with §4408-a of the Public Health Law, dually eligible enrollees retain the right to file complaint appeals for issues related to Medicaid.
    2. MMCP must utilize the Department’s Medicaid model Complaint Appeal Resolution Notice for the purpose of providing written notice to a dually eligible enrollee of a complaint appeal determination for issues related to Medicaid.

IV. Implementation

  1. MMCP operating the MAP Program must utilize their existing Medicaid model notices for these integrated determinations.
  2. MMCP operating the IB-Dual Program may utilize their existing Department-approved Medicaid model Approval, Complaint Resolution, and Complaint Appeal Resolution notices, or may elect to create new Medicaid model Approval, Complaint Resolution, and Complaint Appeal Resolution notices specific to the IB-Dual Program.
  3. MMCP operating the IB-Dual Program who are not already utilizing their existing Department-approved Medicaid model notices for these integrated determinations, must begin utilizing them as soon as possible and no later than 4/14/2026.
  4. MMCP operating the IB-Dual Program who elect to create new Medicaid model Approval, Complaint Resolution, and Complaint Appeal Resolution notices for these integrated determinations must submit their notices to the Department for review and approval prior to use. Newly created notices must be sent to bigaplans@health.ny.gov no later than 4/14/2026.