MLTC Policy 15.03: End of Exhaustion Requirement for MLTC Partial Capitation Plan Enrollees

Office of Health Insurance Programs
Division of Long Term Care
MLTC Policy 15.03: End of Exhaustion Requirement for MLTC Partial Capitation Plan Enrollees
Date of Issuance: July 2, 2015

For all MLTC partial capitation plan decisions made on or after July 1, 2015, that deny, reduce or discontinue enrollees´ services, enrollees may request a State fair hearing from the NYS Office of Temporary and Disability Assistance ("OTDA") immediately.

This change in policy has the following effects:

  1. enrollees are no longer required to exhaust their plan´s internal appeals processes before obtaining a State fair hearing;
  2. aid-continuing is no longer available if the enrollee asks only for an internal appeal of a plan´s proposed reduction or discontinuance of services and does not also timely request a State fair hearing;
  3. to obtain aid-continuing, enrollees must request a State fair hearing within 10 days of the date of the Managed Long Term Care Action Taken notice;
  4. enrollees do not need to specifically request aid-continuing to obtain it, but they may tell OTDA that they specifically decline it; and
  5. the 60 day deadline to request a State fair hearing begins on the date of the Managed Long Term Care Action Taken notice.

Until further notice, this policy change applies only to enrollees in MLTC partial capitation plans. Enrollees in other MLTC products, such as MAP and PACE plans, must continue to exhaust their plan´s internal appeals processes before obtaining a State fair hearing.

If you have questions regarding this matter, please contact your plan manager.