New Rules on Medicaid Home Care Appeals – 2018

New York’s Medicaid Program is experiencing growing pains as the demand for care at home has increased and the hourly wage of the home care worker is also rising. As a result, many recipients of Medicaid’s home care benefit may have the amount or duration of personal care reduced.

The appeal process for challenging a denial, reduction or termination of services has changed. Beginning March 1, 2018, all home care recipients must seek an appeal with the home care agency before requesting a hearing before the New York State Fair Hearing panel. This pre-hearing appeal is an “internal appeal”.

State and federal regulations require plans to mail a written notice of any decision to reduce or terminate services.  This notice must be mailed at least ten (10) calendar days before the effective date of the decision.  Plan members who want services to continue while they appeal a reduction or termination must request an internal appeal with “aid continuing.”  To receive “aid continuing,” the plan member must submit a written appeal request within ten (10) calendar days of the date of the notice or by the effective date of the decision, whichever is later.

The deadline to request an Internal Appeal without aid continuing is sixty (60) calendar days from the date of the notice.

If one disagrees with the outcome of an Internal Appeal, one may request a State Fair Hearing after the plan issues a Final Adverse Determination.  The deadline to request a Fair Hearing is one hundred and twenty (120) days from the date of the Final Adverse Determination.  MLTC members may request a Fair Hearing sooner if the plan fails to provide a written notice of its initial decision, provides inadequate notices, does not decide the Internal Appeal within the required time frame, or fails to comply with other requirements.

Please note that the Internal Appeal process applies to decisions about what services MLTC and Managed Care Plans will provide.  Medicaid beneficiaries who disagree with a decision about their eligibility for Medicaid may request a State Fair Hearing immediately.  The deadline to request a Fair Hearing on a decision by the local Medicaid Agency is sixty (60) days from the date of the notice.  If the Medicaid beneficiary wants “aid continuing,” then the Fair Hearing must be requested before the effective date of the decision, or within ten (10) days of the date of the notice, whichever is later.

Action:  If you wish to appeal a determination of your Medicaid care plan, contact our firm for help in resolving this or any other Medicaid issue.

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