MLTC Policy 14.05(a)

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 14.05(a): Proper Handling of Enrollees´ Requests for Internal Appeals

Date of Issuance: August 20, 2014

This is to remind you regarding the proper handling of enrollees´ requests for internal appeals of proposed reductions or discontinuances of community based long term care services.

Recently, the Department learned that at least one managed long term care ("MLTC") plan, and possibly additional plans, may have treated an enrollee´s request for an internal appeal of the plan´s proposed reduction or discontinuance of services as a request for an increase in services, which the plan then denied. This is improper.

A MLTC plan´s authorization for services for a new period at less than the previous period is a reduction in services. For example, when an enrollee was authorized for 10 hours of services, 7 days per week, and the plan reassesses that enrollee and determines that, for a new service period, the enrollee´s services should be 8 hours of services, 7 days per week, that proposed action is a reduction in services.

The Department recently advised all MLTC plans that, when a plan assesses an enrollee and determines to reduce or discontinue previously authorized services, and the enrollee timely files an internal appeal and asks that benefits be continued pending the outcome of the internal appeal, the enrollee is entitled to receive the previously authorized services unchanged pending the outcome of the internal appeal even if the enrollee´s service authorization has expired. See MLTC Policy 14.05: "Aid-Continuing to be provided without regard to the expiration of a prior service authorization," dated August 6, 2014, and posted at: http://www.health.ny.gov/health_care/medicaid/redesign/mrt90/

The purpose of this additional directive is to remind all MLTC plans that, when a plan proposes to reduce or discontinue an enrollee's previously authorized services, and the enrollee timely contacts the plan to request that the previously authorized services continue unchanged, the plan must not interpret the enrollee's contact as a request for an increase in services. Rather, the plan must treat the enrollee´s contact as a request for an internal appeal of the plan´s proposed reduction or discontinuance of the previously authorized services.

To use the example given above, if a MLTC plan proposes to reduce an enrollee's hours from 10 hours of services, 7 days per week, to 8 hours of services, 7 days per week, and the enrollee contacts the plan and asks that the 10 hours of services, 7 days per week, be maintained or otherwise expresses dissatisfaction with, or confusion about, the proposed reduction in services, the plan must treat the enrollee's contact as a request for an internal appeal of the proposed reduction in services and not as a request for an increase in services from 8 hours per day, 7 days per week, to 10 hours per day, 7 days per week. And, as discussed in MLTC Policy 14.05, the plan must also continue to provide the previously authorized services unchanged pending the outcome of the internal appeal, even if the enrollee´s authorization period has expired.

Should you have questions regarding this matter, please contact your plan manager at (518) 474-6965.