MLTC Policy 25.01: Series of Fair Hearing Backlog Prehearing Disposition Policy

Date of issuance: February 4th, 2025
Effective Date: February 4th, 2025

To: Mainstream Medicaid Managed Care (MMC) Health Plan CEOs and Government Program Liaisons, and
Managed Long Term Care (MLTC) Health Plan CEOs and Government Program Liaisons

Purpose: The purpose of this policy is to describe actions being taken by the Department for the reduction of the Fair Hearing Backlog and subsequent plan requirements. This policy applies to all Managed Care plans, including Managed Long Term Care plans, and is posted here as MLTC Policy 25.01

The Mainstream Policy is posted at the following link under Health Plan Guidelines.

Background: New York State has the largest backlog of fair hearings in the nation, now numbering over 10,000 cases, and New York has received a letter from CMS threatening corrective action for non-compliance. This backlog has been the consequence of many factors, including the Public Health Emergency.

Policy Update: The Department will review and send to plans for Pre-hearing Disposition (PHD) those cases which have aged more than one year, are single issue, have not been scheduled, are receiving Aid-Continuing, and are inadequate, discontinuance, or reduction hearings. Plans are now required to agree to a PHD for cases sent by the Department via a series of batch communications during 2025 unless the plan can provide a compelling reason why a specific hearing should not receive a PHD.

This policy is necessary since these cases have pended for more than one (1) year, meaning that the assessment under which the Fair Hearing was requested is now outdated. The Department will make clear what reasons are not appropriate to reject a PHD in instructions to plans. Plans will have two (2) weeks to review, complete the member spreadsheet, and return an attestation.

Questions should be referred to: