MLTC Policy 15.08: Conflict-Free Evaluation and Enrollment Center Dispute Resolution

Office of Health Insurance Programs
Division of Long Term Care
MLTC Policy 15.08: Conflict Free Evaluation and Enrollment Center (CFEEC) Dispute Resolution Policy
Date of Issuance: December 29, 2015

The purpose of this policy is to provide guidance to the Managed Long Term Care Plans (MLTCPs) on the Dispute Resolution process between Maximus, the Conflict-Free Evaluation and Enrollment Center (CFEEC), and the MLTCP, should there be a disagreement on the consumer´s eligibility for Community Based Long Term Care (CBLTC) services.

When a consumer contacts the CFEEC for an evaluation, a nurse evaluator will complete the Uniform Assessment System (UAS) to determine the consumer´s eligibility for CBLTC. If the consumer is deemed eligible, the CFEEC will warm transfer the consumer to the enrollment broker for education on the MLTCPs available in their area before selecting a plan. If the consumer is not ready to select a plan, the CFEEC nurse will leave educational material in the home to assist with the plan selection process during the call to the enrollment broker. Once a plan is selected, an enrollment application will be submitted to the plan by the CFEEC on the consumer´s behalf. The enrollment process still requires that the MLTCP complete an assessment for the purposes of care plan development.

Should the selected plan disagree with the CFEEC´s determination of CBLTC eligibility, a dispute resolution form must be submitted to CFEEC two business days following the plan assessment and the plan has up to six business days to resolve the issue directly with CFEEC staff. If no resolution is made, the CFEEC will escalate the consumer´s case to the NYS Department of Health (DOH) Medical Professional for review and final determination. The consumer will be notified in writing that their case is under review and a determination will be made within three business days. For the purposes of this policy, the Medical Professional may be Department staff with a medical degree, and an RN, for example, may act in this capacity.

Once a determination has been made by the DOH Medical Professional, the consumer will be informed of the decision as follows:

  • In the event that a denial of enrollment is overturned:
    • If the Medical Professional agrees that the consumer is CBLTC eligible and is therefore eligible to enroll into the selected MLTC plan, the CFEEC will send the consumer a notice indicating that the MLTC plan´s denial of enrollment was overturned.
    • The notice will outline steps on continuing the enrollment process.
    • Should the MLTC plan´s denial of enrollment be overturned by the DOH Medical Professional, the MLTC plan is required to enroll that consumer.
  • In the event that a denial of enrollment is upheld:
    • If the DOH Medical Professional disagrees with the consumer´s CBLTC eligibility and the consumer is therefore not eligible to enroll into the selected MLTC plan, the CFEEC will send the consumer a notice indicating that the MLTC plan´s denial of enrollment was upheld.
    • The notice will include the consumer´s fair hearing rights.