MLTC Update WSIACA October 2018 Valerie Bogart, Director Evelyn Frank Legal Resources Program, NYLAG APPENDIX

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1 . EVELYN FRANK LEGAL RESOURCES PROGRAM MLTC Update WSIACA October 2018 Valerie Bogart, Director Evelyn Frank Legal Resources Program, NYLAG APPENDIX Miscellanous 1. List of MLTC plans in NYC with enrollment as of September Immediate Need Fact Sheet and Attestation Form, HRA Transmittal Form, and sample cover letter... 2 Documents on New Exhaustion Requirement for Appeals Form Notices and Appeal Request Forms -- Exhaustion of Internal Appeals 1. INTERNAL APPEAL DETERMINATION (IAD) With Appeal Request Form (Reduction of Home Care Services) (Sample in hypothetical case. Based on Model notice template at 20_initial_reduce_services.htm FINAL APPEAL DETERMINATION (FAD) With Appeal Request Form (Sample Reduction of Home Care Services) (Note this is missing last 2 pages, same as last 2 pages of Initial Adverse Determination (IAD) foreign language and reasonable accommodation inserts) Based on Model Notice template at 20_final_reduce_services.htm Authorization to Request Appeal or Hearing --NYLAG form - Available to download at BLANK Plan Appeal Request BLANK Fair Hearing Request Consumer Fact Sheets about New Appeal Rules 1. DOH Fact Sheet on Exhaustion NYLAG Fact Sheet on Exhaustion Graphics of steps in appeals Online Resources 1. NYS Webpage on Exhaustion - Service Authorization and Appeals for Mainstream Medicaid Managed Care Plans, HARP, and HIV SNP, at - oriented to training mainstream plans. Includes FAQs, a PowerPoint, policy, notice templates DOH MLTC Webpage MRT 90 links to model contracts, MLTC policies, etc. 7 HANOVER SQ, 18 TH FL NEW YORK NY TEL: (212) FAX: (212) EFLRP@NYLAG.ORG

2 - Webinars, FAQs, notice templates on Exhaustion Mis-Managed Care: Fair Hearing Decisions on Medicaid Home Care Reductions by Managed Long Term Care Plans, July 2016, issued by Medicaid Matters NY and New York Chapter of the National Academy of Elder Law Attorneys, (available at content/uploads/2016/08/managed-long-term-care-fair-hearing-monitoring-project Final.pdf) New York times Article about report 4. Article on Managed Care Appeal Procedures check for updates 5. Fax, phone and contact info to request appeals for all MLTC plans will be posted here when available - HOTLINES/ COMPLAINTS 1. NYS DOH MLTC/FIDA Complaint Hotline mltctac@health.ny.gov 2. NYS DOH Mainstream managed care complaints managedcarecomplaint@health.ny.gov 3. ICAN Independent Consumer Advocacy Network Helps with MLTC and mainstream appeals on long term services and supports -- TEL TTY Relay Service: 711 Website: icannys.org ican@cssny.org SEE OUR Health Care Advocacy Webpage 2 of 2

3 plan Apr-13 Feb. 14 Mar-17 Sep.-18 Notes re closed plans 1. CENTERS PLAN FOR HEALTHY 149 1,059 14,345 26,216 LIVING 2. Senior Whole Health ,373 13, SENIOR HEALTH PARTNERS (HealthFirst) 8,088 10,575 12,743 13, ELDERSERVE 8,282 9,888 10,532 11, ELDERPLAN (HomeFirst) 7,572 10,395 10,609 10, VillageCareMAX 1,687 2,461 7,466 10, INTEGRA (Personal Touch) 628 4,830 10, VNS CHOICE 19,360 17,045 11,376 9, Fidelis 4,224 5,206 7,577 7, GUILDNET 10,602 11,473 10,594 7,332 Closing Jan AgeWell New York (Parker Jewish) 363 1,716 5,963 6, INDEPENDENCE CARE 4,382 5,046 6,504 6,077 SYSTEMS 13. AMERIGROUP/HealthPlus 2,726 2,895 4,176 5, Aetna 390 1,647 3,145 4, EXTENDED MLTC 155 1,867 4, WELLCARE 4,166 5,206 4,887 3, Archcare MLTC 217 1,295 1,714 2, United Health Care ,899 2, MetroPlus ,460 1, MONTEFIORE HMO 23 1,069 1, ALPHACARE (Magellan) 246 3,414 0 transferred to Senior Whole Health 22. CenterLight 7,566 9, transferred to Centers Plan 11/ HHH CHOICES 1,973 2, closed 24. HIP transferred to Guildnet 12/ North Shore LIJ 187 2,604 0 transferred to Centers Plan 9/2017 Total NYC - MLTC 82, , , ,469 NYC MLTC Enrollment by Plan Over 5 years - in order of Largest to Smallest MLTC plan in August 2018 Data from Medicaid Managed Care Enrollment Reports, available at -1-

4 Fast-Track Medicaid Applications If you have an IMMEDIATE NEED for Personal Care or Consumer-Directed Personal Assistance Services NYC If you apply for Medicaid in order to enroll in a Managed Long Term Care (MLTC) plan, it can take 3 4 months or more before you are actually enrolled in a plan and start receiving home care. The Medicaid application takes about 6 weeks to process, then it takes 2 weeks to schedule a Conflict Free assessment by New York Medicaid Choice, then another 2-3 weeks while you ask MLTC plans to schedule a nursing assessment, so that you can select a plan and enroll. The plan must submit the signed enrollment form by the 19 th of the month for enrollment to start the 1 st of the next month. If you miss that deadline, enrollment is delayed another month. If you have an IMMEDIATE NEED for Medicaid home care, you can apply at your local Medicaid program and get Medicaid approved and home care started in 2-3 weeks. If you don t have Medicaid, you can apply for Medicaid AND home care at the same time. If you already have Medicaid, you just ask for immediate need home care. You can apply whether you are home, in a hospital, or nursing home. In New York City, submit the following documents in person, by mail or fax to: HRA--HCSP Central Medicaid Unit FAX Atlantic Avenue, 7th Floor Brooklyn, NY HRA HCSP Transmittal Form HCSP Cover form in NYC 2. Medicaid application with all required documents. This must include "Supplement A" (DOH-4495A in NYC) (alternate languages and formats of forms posted at this link). See more about Medicaid eligibility here. 1. If you already have Medicaid, submit the approval notice and CIN number. 2. If an application was submitted and is pending, submit a copy of it along with all documentation, and proof of when and where it was filed. 3. Physician's order/ Form M11q in NYC - Must be current, meaning that your doctor saw you and signed the form less than 30 days before you submit it. See tips at Q-Tips. Doctor may attach extra comments describing your needs. 4. Attestation of Immediate Need (OHIP 0103) -- Consumer must sign this form to attest to immediate need. Form is attached. You have an immediate need even if your family has been providing some assistance, if that assistance is not enough or cannot continue. Explain the particular facts in a COVER LETTER. 7 HANOVER SQ, 7 TH FL NEW YORK NY FAX: (212) EFLRP INTAKE TEL: (212) or EFLRP@NYLAG.ORG -2-

5 5. Married applicants whose spouse does not need or receive Medicaid can request spousal impoverishment budgeting, which allows the couple to keep about $3400 in combined income and $90,000 in combined assets. You may not need to use Spousal Refusal or a Pooled Income Trust with this budgeting. Use the DOH "Request for Assessment" form to request spousal budgeting (page 9 of this link) 6. HIPAA release - OCA Form No Authorization for Release of Health Information Pursuant to HIPAA 7. If you are requesting Consumer Directed assistance, include a completed application for CDPAP 8. If you will need a pooled trust, submitting it now will slow down the application. If you do submit it (with all of the documents listed in then in cover letter request that you be initially budgeted with a spend-down, until the trust is approved. 9. Cover letter that explains: why you have an "immediate need" for services, gives contact info for a family member or friend to arrange home visits for assessment and explains who will be directing care if the applicant has dementia, requests spousal impoverishment budgeting if helpful for married applicant if you are requesting CDPAP, explain your plan for arranging care if you are submitting a pooled trust, request that you be initially budgeted with a spend-down, until the trust is approved. What Happens After I Submit the Application Package? In the next 12 days, the Medicaid office should process your Medicaid application, send a nurse to your home to assess your need for home care, and authorize you for personal care or CDPAP services provided by an agency that contracts with NYC. They may ask you to provide some additional documents. After the home care services are provided for 120 days, you will receive a notice from New York Medicaid Choice, a state contractor that serves as the enrollment broker for all managed care programs. The notice will explain that you need to select and enroll in an Managed Long Term Care (MLTC) plan within 60 days If you do not select one, you will be auto-assigned to one. 1 Links to all forms and links in this fact sheet can be found here - See also DOH website of 2

6 Attestation of Immediate Need for Personal Care Services/Consumer Directed Personal Assistance Services I, attest that I am in need of immediate Personal Care Services (Name) or Consumer Directed Personal Assistance Services. I also attest that: no voluntary informal caregivers are available, able and willing to provide or continue to provide needed assistance to me; no home care services agency is providing needed assistance to me; adaptive or specialized equipment or supplies including but not limited to bedside commodes, urinals, walkers or wheelchairs, are not in use to meet, or cannot meet, my need for assistance; and third party insurance or Medicare benefits are not available to pay for needed assistance. I certify that the information on this form is correct and complete to the best of my knowledge. X SIGNATURE OF APPLICANT/ REPRESENTATIVE DATE SIGNED Individuals Receiving Long Term Care Services in a Nursing Home or Hospital Setting If you are receiving long term care services in a nursing home or a hospital setting and intend to return home, you may have your eligibility for Personal Care Services or Consumer Directed Personal Assistance Services processed more quickly. Follow the directions on the previous page and fill in the information requested below. I am in a nursing home or a hospital setting and have a date set to return home on. DATE Contact me or my legal representative by calling. New York State Department of Health OHIP

7 IMMEDIATE NEED FOR PERSONAL CARE SERVICES/CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES: INFORMATIONAL NOTICE AND ATTESTATION FORM If you think you have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), such as housekeeping, meal preparation, bathing, or toileting, your eligibility for these services may be processed more quickly if you meet the following conditions: You have no informal caregivers available, able and willing to provide or continue to provide care; You are not receiving needed help from a home care services agency; You have no adaptive or specialized equipment or supplies in use to meet your needs; and You have no third party insurance or Medicare benefits available to pay for needed help. If you don t already have Medicaid coverage, and you meet the above conditions, you may ask to have your Medicaid application processed more quickly by sending in: a completed Access NY Health Insurance Application (DOH-4220); the Access NY Supplement A (DOH-4495A or DOH-5178A), if needed; a physician s order for services; and a signed * Attestation of Immediate Need. If you already have Medicaid coverage that does not include coverage for community-based long term care services, you must send in a completed Access NY Supplement A (DOH-4495A or DOH- 5178A), a physician s order for services and a signed * Attestation of Immediate Need. If you already have Medicaid coverage that includes coverage for community-based long term care services, you must send in a physician s order for services and a signed * Attestation of Immediate Need. If you don t already have Medicaid coverage or you have Medicaid coverage that does not include coverage for community-based long term care services: All of the required forms (see the appropriate list, above) must be sent in to your local social services office or, if you live in NYC, to the Human Resources Administration (HRA). As soon as possible after receiving all of these forms, the social services office/hra will then check to make sure that you have sent in all the information necessary to determine your Medicaid eligibility. If more information is needed, they must send you a letter, by no later than four days after receiving these required forms, to request the missing information. This letter will tell you what documents or information you need to send in and the date by which you must send it. By no later than 7 days after the social service office/hra receives the necessary information, they must let you know if you are eligible for Medicaid. By no later than 12 days after receiving all the necessary information, the social services office/hra will also determine whether you could get PCS or CDPAS if you are found eligible for Medicaid. You cannot get this home care from Medicaid unless you are found eligible for Medicaid. If you are found eligible for Medicaid and PCS or CDPAS, the social services office/hra will let you know and you will get the home care as quickly as possible. If you already have Medicaid coverage that includes coverage for community-based long term care services: The physician s order and the signed Attestation of Immediate Need must be sent to your local social services office or HRA. By no later than 12 days after receiving these required forms, the social services office/hra will determine whether you can get PCS or CDPAS. If you are found eligible for PCS or CDPAS, the social services official/hra will let you know and you will get the home care as quickly as possible. The necessary forms may be obtained from your local department of social services or are available to be printed from the Department of Health s website at: *Found on the back side of this page. New York State Department of Health OHIP

8 IMMEDIATE NEED TRANSMITTAL TO THE HOME CARE SERVICES PROGRAM HCSP-3052 (E) 09/19/2016 DATE: CONSUMER S NAME: LAST 4 DIGITS OF CONSUMER S SSN: From NAME OF SUBMIITING ORGANIZATION STREET ADDRESS CITY, STATE, ZIP CODE To: HOME CARE SERVICES PROGRAM IMMEDIATE NEEDS 785 ATLANTIC AVENUE, 7 th Floor BROOKLYN, NY I am submitting this application package on behalf of the above named consumer for processing as an Immediate Need for home care services. S/he wishes to be enrolled in the following program (check one): Personal Care (PCS) Consumer Directed Personal Assistance (CDPAS) I understand that the documentation listed in the table(s) below is required for this request to be processed. All are attached and appear to be fully completed. For all Immediate Need Requests OHIP-0103, Attestation of Immediate Need HCSP M-11q, Medical Request for Home Care OCA-960, Authorization for Release of Health Information Pursuant to HIPAA Also required, in addition to the three items listed above, if the consumer already has Medicaid coverage, but it does not include long term care coverage DOH-4495A, Access NY Supplement A All necessary proofs that apply to this supplemental form only, as detailed in the DOH-4220 Documents Needed When You Apply For Public Health Insurance section Also, required in addition to everything listed in both tables above, if the consumer does not already have Medicaid coverage at all DOH-4220, Access NY Insurance Application All necessary proofs as detailed in the DOH-4220 Documents Needed When You Apply For Public Health Insurance section Though not required, I understand that submission of a cover letter that includes an explanation of the immediate need, the status of consumer s current whereabouts, a listing of submitted documents, the type of service requested (PCS or CDPAS), is strongly recommended. I have attached a cover letter I have not submitted a cover letter Print Name: Sign Name: Telephone Number: -6-

9 . DATE By Hand or by e-fax: Human Resources Administration HCSP Central Medicaid Unit - IMMEDIATE NEED PROCESSING 785 Atlantic Avenue, 7th Floor Brooklyn, NY RE: Medicaid Application for IMMEDIATE NEED PERSONAL CARE SERVICES NAME -- DOB SSN Last 4 digits xxxx address To Whom It May Concern: Enclosed please find an initial, complete application for the above-named Applicant for Community Medicaid with Community Based Long Term Care Coverage. Because the Applicant has a medical need for Personal Care Services to start immediately, a signed Medical Request for Home Care/ Physician s Order for Personal Care Services (hereafter M11q ) is also attached, along with the Attestation of Immediate Need. The applicant, age [ ], needs.. For these reasons applicant requests assistance during a xxhour span of time xx days/week. OTHER HOME CARE [ why CHHA or other care is insufficient] The applicant has no informal caregivers able and willing to provide assistance with personal care services. [EXPLAIN ] This applicant would be at risk if forced to wait until she can enroll in a Managed Long Term Care plan, which would take an estimated three months or more days for processing the application, 1-2 weeks for the conflict-free assessment, another 1-2 weeks for an MLTC plan to assess and enroll her, and then a delay until enrollment begins the 1 st of the of the next month or often the second following month. Given this immediate need: 1. We ask HRA HCSP to process this application pursuant to the Immediate Need directives, NYS DOH OHIP ADM 16 ADM-02 - Immediate Need for Personal Care Services and Consumer Directed Personal Assistance Services, and the NYC HRA MICSA Alert dated Oct. 19, [IF MARRIED AND NEED --] We ask for Spousal Impoverishment protections to be used so there is no spend-down. 7 HANOVER SQ, 18 TH FL NEW YORK NY FAX: (212) EFLRP INTAKE TEL: (212) or EFLRP@NYLAG.ORG

10 3. [IF IN NURSING HOME Please conduct the requisite assessments at NURSING HOME address Contact xxx, social worker, TEL ] 4. In order to arrange a home visit if necessary, while applicant is still in rehab facility, please contact [ son NAME PHONE] Thank you for your prompt processing of this Medicaid application and Request for Home Care. Sincerely, NAME Direct TITLE ORGANIZATION Direct Dial Fax Enclosures: 1. Medical Request for Home Care- Form HCSP-M11Q, signed xxx 2. Attestation of Immediate Need, signed 11/4/16 3. Authorization for Disclosure of Indiv. Health Insurance Information Form OCA [Power of Attorney ] 5. Medicaid Application- Form DOH Supplement A- Form DOH-4495A 7. Medicare card applicant 8. Passport - applicant 9. Proof of address 10. Proof of income Required Minimum Distributions (Social Security income shown in bank statements) 11. Proof of resources most recent bank statement of 2

11 ACME MLTC PLAN 100 Acme Lane New York, NY MCO-PLAN April 1, 2018 INITIAL ADVERSE DETERMINATION NOTICE TO REDUCE, SUSPEND OR STOP SERVICES Jane Doe 111 Consumer Lane New York, NY Enrollee Number: 5555 Coverage Type: Managed Long Term Care Service: Personal Care services Provider: Helping Hands Home Care Plan Reference Number: Dear Jane Doe: This is an important notice about your services. Read it carefully. If you think this decision is wrong, you can ask for a Plan Appeal by May 31, If you want to keep your services the same until your Plan Appeal is decided, you must ask for a Plan Appeal by April 11, You are not responsible for payment of covered services and this is not a bill. Call this number if you have any questions or need help: MCO-PLAN. Why am I getting this notice? You are getting this notice because ACME MLTC Plan is reducing the service(s) you are getting now. Before this decision, from April 1, 2017 to April 11, 2018, the plan approved: 12 hours/day x 7 days/week of personal care services total 84 hours/week On April 11, 2018 the plan approval changes to: 8 hours/day x 5 days/week and 4 hours/day x 2 days/week total 48 hours/week From April 11, 2018 to October 11, We will review your care again in six months. This service will be provided by a participating provider. You are not responsible for any extra payments, but you will still have to pay your regular co-pay if you have one. Why did we decide to reduce your service? ACME MLTC Plan is taking this action because the service is not medically necessary. Your personal care services will be reduced because: o Your social circumstances have changed since the previous authorization was made. o On January 1, 2018, your daughter, with whom you live, retired from her job. You no longer meet the criteria for your current level of service because: -9- Page 1 of 8

12 o Your daughter is ready, willing and able to take care of you during some of the time that you previously had personal care services. What if I don t agree with this decision? If you think our decision is wrong, you can tell us why and ask us to change our decision. This is called a Plan Appeal. There is no penalty and we will not treat you differently because you asked for a Plan Appeal. If you want to keep your services the same You must ask for a Plan Appeal within 10 calendar days or by the date this decision takes effect, whichever is later. The last day to ask for a Plan Appeal and keep your services the same is April 11, 2018, Your services will stay the same until we make our decision. If the Plan Appeal is not decided in your favor, you may have to pay for the services you got while waiting for the decision. You have a total of 60 calendar days from the date of this notice to ask for a Plan Appeal. The deadline to ask for a Plan Appeal is May 31, Who can ask for a Plan Appeal? You can ask for a Plan Appeal, or have someone else ask for you, like a family member, friend, doctor, or lawyer. If you told us before that someone may represent you, that person may ask for the Plan Appeal. If you want someone new to act for you, you and that person must sign and date a statement saying this is what you want. Or, you can both sign and date the attached Plan Appeal Request Form. If you have any questions about choosing someone to act for you, call us at: MCO-PLAN. TTY users call TTY. You can also call the Independent Consumer Advocacy Network (ICAN) to get free, independent advice about your coverage, complaints, and appeals options. They can help you manage the appeal process. Contact ICAN to learn more about their services: Phone: (TTY Relay Service: 711) Web: ican@cssny.org] How do I ask for a Plan Appeal? You can call, write or visit us to ask for a Plan Appeal. You or your provider can ask for your Plan Appeal to be fast tracked if you think a delay will cause harm to your health. If you need help, or need a Plan Appeal right away, call us at MCO-PLAN. Step 1 Gather your information. When you ask for a Plan Appeal, or soon after, you will need to give us: Your name and address Enrollee number -10- Page 2 of 8

13 Service you asked for and reason(s) for appealing Any information that you want us to review, such as medical records, doctors letters or other information that explains why you need the service. If your Plan Appeal is fast tracked, there may be a short time to give us information you want us to review. To help you prepare for your Plan Appeal, you can ask to see the guidelines, medical records and other documents we used to make this decision. You can ask to see these documents or ask for a free copy by calling MCO-PLAN. Step 2 Send us your Plan Appeal. Give us your information and materials by phone, fax, , mail, online, or in person: Phone MCO-PLAN Fax MCO-EFAX .. appeals@acme.com Mail or In Person.... ACME MLTC PLAN, 100 Acme Lane, New York, NY ATTENTION: APPEALS On Line.. [web portal] If you ask for a Plan Appeal by phone, unless it is fast tracked, you must also send your Plan Appeal to us in writing. To send a written Plan Appeal, you may use the attached Appeal Request Form, but it is not required. Keep a copy of everything for your records. What happens next? We will tell you we received your Plan Appeal and begin our review. We will let you know if we need any other information from you. If you asked to give us information in person, ACME MLTC Plan will contact you (and your representative, if any). We will send you a free copy of the medical records and any other information we will use to make the appeal decision. If your Plan Appeal is fast tracked, there may be a short time to review this information. We will send you our decision in writing. If fast tracked, we will also contact you by phone. If you win your Plan Appeal, your service will be covered. If you lose your Plan Appeal, we will send you our Final Adverse Determination. The Final Adverse Determination will explain the reasons for our decision and your appeal rights. If you lose your appeal, you may request a Fair hearing and, in some cases, an External Appeal. When will my Plan Appeal be decided? Standard We will give you a written decision as fast as your condition requires but no later than 30 calendar days after we get your appeal. Fast Track We will give you a decision on a fast track Plan Appeal within 72 hours after we get your appeal. Your Plan Appeal will be fast tracked if: Delay will seriously risk your health, life, or ability to function; -11- Page 3 of 8

14 Your provider says the appeal needs to be faster; You are asking for more of a service you are getting right now; You are asking for home care services after you leave the hospital; You are asking for more inpatient substance abuse treatment at least 24 hours before you are discharged; or You are asking for mental health or substance abuse services that may be related to a court appearance. If your request for a Fast Track Plan Appeal is denied, we will let you know in writing and will review your appeal in the standard time. For both Standard and Fast Track - If we need more information about your case, and it is in your best interest, it may take up to 14 days longer to review your Plan Appeal. We will tell you in writing if this happens. You or your provider may also ask the plan to take up to 14 days longer to review your Plan Appeal. Can I ask for a State Fair Hearing? You have the right to ask the State for a Fair Hearing about this decision, after you ask for a Plan Appeal and: You receive a Final Adverse Determination. You will have 120 days from the date of the Final Adverse Determination to ask for a Fair Hearing; OR The time for us to decide your Plan Appeal has expired, including any extensions. If you do not receive a response to your Plan Appeal or we do not decide in time, you can ask for a Fair Hearing. To request a Fair Hearing call or fill out the form online at Do I have other appeal rights? You have other appeal rights if your plan said the service was: 1) not medically necessary, 2) experimental or investigational, 3) not different from care you can get in the plan s network, or 4) available from a participating provider who has correct training and experience to meet your needs. For these types of decisions, if we do not answer your Plan Appeal on time, the original denial will be reversed. For these types of decisions, you may also be eligible for an External Appeal. An External Appeal is a review of your case by health professionals that do not work for your plan or the State. You may need your doctor s help to fill out the External Appeal application. Before you ask for an External Appeal: You must file a Plan Appeal and get the plan s Final Adverse Determination; or If you ask for a Fast Track Plan Appeal, you may also ask for a Fast Track External Appeal at the same time; or You and your plan may jointly agree to skip the Plan Appeal process and go directly to the External Appeal. You have 4 months to ask for an External Appeal from when you receive your plan s Final Adverse Determination, or from when you agreed to skip the Plan Appeal process Page 4 of 8

15 To get an External Appeal application and instructions: Call ACME MLTC Plan at1-800-mco-plan; or Call the New York State Department of Financial Services at ; or Go on line: The External Appeal decision will be made in 30 days. Fast track decisions are made in 72 hours. The decision will be sent to you in writing. If you ask for an External Appeal and a Fair Hearing, the Fair Hearing decision will be the final decision about your benefits. Other help: You can file a complaint about your managed care at any time with the New York State Department of Health by calling for MLTC complaints You can call ACME MLTC PLAN at MCO-PLAN if you have any questions about this notice. Sincerely, ACME MLTC Plan Enclosure: cc: Appeal Request Form Requesting Provider At your request, a copy of this notice has been sent to: John Doe Authorized Representative Chris Roe Legal Guardian -13- Page 5 of 8

16 ACME MLTC PLAN APPEAL REQUEST FORM FOR SERVICES BEING REDUCED, SUSPENDED, OR STOPPED Mail To: Fax to: MCO-EFAX ACME MLTC Plan [Address] [City, State Zip] Today s date: April 1, 2018 DEADLINE: If you want to keep your services the same until the Plan Appeal decision, you must ask within 10 calendar days of the date of this notice, or by the date the decision takes effect, whichever is later. (If you lose your appeal you may have to pay for services you got while waiting for the decision.) The last day to ask for a Plan Appeal to keep your services the same is April 11, 2018 You have a total of 60 calendar days from the date of this notice to ask for a Plan Appeal. The last day to ask for a Plan Appeal for this decision is May 31, If you want a Plan Appeal, you must ask for it on time. Enrollee Information Name: Jane Doe] Enrollee ID: 5555 Address: 111 Consumer Lane, New York, NY Home Phone: Cell Phone: [Cell Phone] Plan Reference Number: Service being reduced, suspended or stopped: Personal Care Services I think the plan s decision is wrong because: Check all that apply: I do NOT want my services to stay the same while my Plan Appeal is being decided. I request a Fast Track Appeal because a delay could harm my health. I enclosed additional documents for review during the appeal. I would like to give information in person. I want someone to ask for a Plan Appeal for me: Have you authorized this person with ACME MLTC Plan before? YES NO Do you want this person to act for you for all steps of the appeal or fair hearing about this decision? You can let us know if change your mind. YES NO Requester (person asking for me): Name: E- mail: Address: City: State: Zip Code: Phone #: ( ) Fax #: ( ) Enrollee Signature: Date: Requester Signature: Page 6 of 8 Date: If this form cannot be signed, the plan will follow up with the enrollee to confirm intent to appeal. -14-

17 NOTICE OF NON-DISCRIMINATION ACME MLTC PLAN complies with Federal civil rights laws. ACME MLTC PLAN does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. ACME MLTC PLAN provides the following: Free aids and services to people with disabilities to help you communicate with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats) Free language services to people whose first language is not English, such as: Qualified interpreters Information written in other languages If you need these services, call ACME MLTC PLAN at <toll free number>. For TTY/TDD services, call <TTY>. If you believe that [ACME MLTC PLAN] has not given you these services or treated you differently because of race, color, national origin, age, disability, or sex, you can file a grievance with [ACME MLTC PLAN] by: Mail: Phone: Fax: In person: [ADDRESS], [CITY], [STATE] [ZIP CODE], [PHONE NUMBER] (for TTY/TDD services, call <TTY>) [FAX NUMBER] [ADDRESS], [CITY], [STATE] [ZIP CODE] [ ADDRESS] You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights by: Web: Office for Civil Rights Complaint Portal at Mail: U.S. Department of Health and Human Services 200 Independence Avenue SW., Room 509F, HHH Building Washington, DC Complaint forms are available at Phone: (TTY/TDD ) -15- Page 7 of 8

18 ATTENTION: Language assistance services, free of charge, are available to you. Call <toll free number> <TTY/TDD>. ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al <toll free number> <TTY/TDD>. 注意 : 如果您使用繁體中文, 您可以免費獲得語言援助服務 請致電 <toll free number> <TTY/TDD>. ملحوظة: إذا كنت تتحدث اذكر اللغة فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم toll free هاتف الصم والبكمnumber <)رقم TTY/TDD 주의 : 한국어를사용하시는경우, 언어지원서비스를무료로이용하실수있습니다 <toll free number> <TTY/TDD> 번으로전화해주십시오. ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните <toll free number> (телетайп: TTY/TDD). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero <toll free number> <TTY/TDD>. ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le <toll free number> <TTY/TDD>. English Spanish Chinese Arabic Korean Russian Italian French ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele <toll free number> <TTY/TDD>. אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון אפצאל. רופט number/tty/tdd<.toll free UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer <toll free number> <TTY/TDD> PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa <toll free number/tty/tdd>. লক ষ য কর ন যদ আপদন ব ল, কথ বলত প ত ন, হতল দন খ চ য় ভ ষ সহ য় পদ তষব উপলব ধ আত ফ ন কর ন ১1-800-MCO-PLAN TTY: TTY KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në <toll free number> <TTY/TDD>. ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε <toll free number> <TTY/TDD>. خبردار: اگر آپ اردو بولتے ہیں تو آپ کو زبان کی مدد کی خدمات مفت میں دستیاب ہیں کال کریں < toll.>:free number> <TTY French Creole Yiddish Polish Tagalog Bengali Albanian Greek Urdu -16- Page 8 of 8

19 FINAL APPEAL DETERMINATION (FAD) With Appeal Request Form Reduction of Home Care Services -17-

20 [Ultra-Health MLTC Plan ] [Address] [Phone] FINAL ADVERSE DETERMINATION NOTICE TO REDUCE, SUSPEND OR STOP SERVICES May 1, 2018 Jane Doe W. 96 th St. New York, NY Enrollee Number: xxxx Coverage type: Personal Care Services Plan reference number: Provider: Happy Home Care Dear Jane Doe: This is an important notice about your services. Read it carefully. If you think this decision is wrong, you have four months to ask for an External Appeal or you can ask for a Fair Hearing by August 28, 2018, If you want to keep your services the same until your Fair Hearing is decided, you must ask for a Fair Hearing by May 11, You are not responsible for payment of covered services and this is not a bill. Call this number if you have any questions or need help MCO-PLAN. Why am I getting this notice? You are getting this notice because on April 5, 2018 you or your provider asked for a Plan Appeal about our decision to reduce personal are services. On April 30, 2018 Ultra-Health decided we are changing our decision and will partially approve your service. From April 1, 2017 to April 11, 2018, the plan approved: 12 hours/day x 7 days/week of personal care services total 84 hours/week On April 1, 2018 we decided to reduce your personal care services from 12 hours/day x 7 days/week starting on April 11, 2018 to: 8 hours/day x 5 days/week and 4 hours/day x 2 days/week total 48 hours/week On May 1, 2018, we have partially denied your Plan Appeal and: On May 11, 2018, we will reduce your personal care services to 10 hours/day x 5 days/week and 4 hours/day x 2 days/week total 58 hours/week We will review your care again in 6 months. This service will be provided by a participating provider. You are not responsible for any extra payments, but you will still have to pay your regular co-pay if you have one. Page 1 of 7-18-

21 Why did we reduce your service? We made this decision because the service is not medically necessary Your personal care services will be reduced because: Your personal care services will be reduced because: o Your social circumstances have changed since the previous authorization was made. o On January 1, 2018, your daughter, with whom you live, retired from her job. You no longer meet the criteria for your current level of service because: o Your daughter is ready, willing and able to take care of you during some of the time that you previously had personal care services. This decision was made under 42 CFR Sections and ; NYS Social Services Law Sections 364-j(4)(k) and 365-a(2); 18 NYCRR Section What if I don t agree with this decision? If you think this decision is wrong: You can ask the State for a Fair Hearing and an Administrative Law Judge will decide your case. If we said your service was not medically necessary, you can ask the State for an External Appeal this may be the best way to show how this service is medically necessary for you. Your services may change while you are waiting for an External Appeal decision. If you ask for both a Fair Hearing and an External Appeal, the Fair Hearing decision will be the final answer about your benefits. If you want to keep your services the same You must ask for a Fair Hearing within 10 calendar days or by the date this decision takes effect, whichever is later. The last day to ask for a Fair Hearing and keep your services the same is May 11, 2018 Your services will stay the same until we make our decision. If the Plan Appeal is not decided in your favor, you may have to pay for the services provided while waiting for the decision. You have a total of 120 calendar days from the date of this notice to ask for a Fair Hearing. The deadline to ask for a Fair Hearing is August 28, How Can I Ask for a Fair Hearing? To ask for a Fair Hearing, you can: Call: (TTY call 711 and ask operator to call ) Page 2 of 7-19-

22 Request online using the form at: Use the Managed Care Fair Hearing Request Form that came with this notice. Return it with this notice by mail, fax, or in person. Keep a copy of the request and notice for yourself. MAIL FAIR HEARING REQUEST FORM TO: New York State Office of Temporary and Disability Assistance Office of Administrative Hearings Managed Care Unit P.O. Box Albany, New York OR FAX FAIR HEARING REQUEST FORM TO: WALK IN New York City Only: Office of Temporary and Disability Assistance Office of Administrative Hearings 14 Boerum Place - 1st Floor Brooklyn, New York After you ask for a Fair Hearing, the State will send you a notice with the time and place of the hearing. At the hearing you will be asked to explain why you think this decision is wrong. A hearing officer will hear from both you and the plan and decide whether our decision was wrong. To prepare for the hearing: We will send you a copy of the evidence packet before the hearing. This is information we used to make our decision about your services. We will give this information to the hearing officer to explain our decision. If there is not time enough to mail it to you, we will bring a copy of the evidence packet to the hearing for you. If you do not get the evidence packet by the week before your hearing, you can call [1-800 MCO-PLAN] to ask for it. You have the right to see your case file and other documents. Your case file has your health records and may have more information about why your health care service was changed or not approved. You can also ask to see guidelines and any other document we used to make this decision. You can call [1-800 MCO-PLAN] to see your case file and other documents, or to ask for a free copy. Copies will only be mailed to you if you say you want them to be mailed. You have a right to bring a person with you to help you at the hearing, like a lawyer, a friend, a relative or someone else. At the hearing, you or this person can give the hearing officer something in writing, or just say why the decision was wrong. You can also bring people to speak in your favor. You or this person can also ask questions of any other people at the hearing. You have the right to submit documents to support your case. Bring a copy of any papers you think will help your case, such as doctor s letters, health care bills, and receipts. It may be helpful to bring a copy of this notice and all the pages that came with it to your hearing. You may be able to get legal help by calling your local Legal Aid Society or advocate group. To locate a lawyer, check your Yellow Pages under Lawyers or go to In New York City, call 311. Page 3 of 7-20-

23 After the hearing, you will be sent a written decision about your case. How can I ask for an External Appeal? You have four months from receipt of this notice to ask for an External Appeal. A description of your External Appeal rights and an application is attached to this notice. To ask for an External Appeal fill out and return the application to the New York State Department of Financial Services. You may need your doctor s help to fill out the External Appeal application. You can call the New York State Department of Financial Services at for help. The External Appeal decision will be made in 30 days. Your appeal will be fast tracked if your provider says the appeal needs to be faster. If your External Appeal is fast tracked, a decision will be made in 72 hours. The decision will be sent to you in writing.] Other Help: You can file a complaint about your managed care at any time with the New York State Department of Health by calling for MLTC [ ]. You can call the Independent Consumer Advocacy Network (ICAN) to get free, independent advice about your coverage, complaints, and appeals options. They can help you manage the appeal process. Contact ICAN to learn more about their services: Phone: (TTY Relay Service: 711) Web: ican@cssny.org] You can call [CONTACT PERSON NAME] at Ultra-Health MLTC Plan at [1-800-MCO-PLAN] if you have any questions about this notice. Sincerely, MCO/UR AGENT/BENEFIT MANAGER Representative Enclosure: cc: Managed Care Fair Hearing Request Form External Appeal Standard Description and Application Requesting Provider {Plans must send a copy of this notice to parties to the appeal including, but not limited to authorized representatives, legal guardians, designated caregivers, etc. Include the following when such parties exist:} [At your request, a copy of this notice has been sent to: [DAUGHTER]] Page 4 of 7-21-

24 [266] MLTC MANAGED CARE DECISION FAIR HEARING REQUEST FORM AC MAIL TO: NYS Office of Temporary and Disability Assistance FAX TO: Office of Administrative Hearings Managed Care Unit P.O. Box Albany, New York DEADLINE: If you want to keep your services the same until the Fair Hearing decision, you must ask within 10 calendar days of the date of this notice, or by the date the decision takes effect, whichever is later. The last day to ask to keep your services the same is May 11, 2018 You have a total of 120 calendar days from the date of this notice to ask for a Fair Hearing. The last day to ask for a Fair Hearing is August 28, If you want a Fair Hearing, you must ask for it on time. I want a Fair Hearing. This decision is wrong because: Enrollee Name Signature Phone Representative (if any) Name Relationship Signature Phone Your service WILL NOT CHANGE until the Fair Hearing decision if you ask for a Fair Hearing by May 11, 2018 If you lose your Fair Hearing you may have to pay for services you got while waiting for the decision. Check this box only if you do not want to keep your health care the same: I DO NOT want to keep my health care the same. I agree that the plan can reduce, suspend or stop my services as described in this notice before my Fair Hearing decision is issued. FOR NYS OTDA ONLY Notice Date [DATE] Effective [DATE] Service Type:[Service] Case Name (c/o, if present) and Address: CIN: [MEDICAID CIN] [ENROLLEE NAME ENROLLEE ADDRESS] MANAGED CARE DECISION FAIR HEARING REQUEST FORM [MCO/URA NAME MCO/URA ADDRESS] Reference No.: [MCO REFERENCE NUMBER] A Plan Appeal was filed on April 5, On May 1,2018, [Plan Name] decided we are changing our previous decision and will partially approve the service. From April 1, 2017 to April 11, 2018, the plan approved: 12 hours/day x 7 days/week of personal care services total 84 hours/week On April 1, 2018 we decided to reduce your personal care services from 12 hours/day x 7 days/week starting on April 11, 2018 to: 8 hours/day x 5 days/week and 4 hours/day x 2 days/week total 48 hours/week On May 1, 2018, we have partially denied your Plan Appeal and: On May 11, 2018, we will reduce your personal care services to 10 hours/day x 5 days/week and 4 hours/day x 2 days/week total 58 hours/week Page 5 of 7-22-

25 Authorization to Request Appeal or Hearing -23-

26 AUTHORIZATION Medicaid Managed Care Requests I authorize the following individuals or organizations to represent me in making requests regarding my Medicaid managed care or Managed Long Term Care Services. They may, on my behalf make requests including but not limited to: 1. Request a Plan Appeal, including request aid continuing pending final decision by the plan, of an adverse determination by my plan; 2. Request a Fair Hearing, including request aid continuing pending the final decision by the Office of Temporary and Disability Assistance, of an adverse determination by my plan; 3. Request prior approval of a new service or of additional hours or amounts of a service that I receive ( concurrent review ). 4. File a complaint with my plan. 5. File a complaint with the NYS Department of Health. This authorization applies to my current plan, which is (NAME) and also to any different plan I might enroll in at a later date. This authorization expires after:. Authorized Individuals or Organizations (fill in and check one or more): NAME Relationship o Address o Cell phone I want this person to act for me for all steps of the appeal or fair hearing or authorize them to appoint a representative to act for me. ORGANIZATION NAME o Relationship (CIRCLE: senior center, case management agency, clinic, attorney, geriatric care manager) OTHER: o Contact person: o Address o Phone I want this organization to act for me for all steps of the appeal or fair hearing or authorize it to appoint a representative to act for me. Independent Consumer Advocacy Network (ICAN) - including all participating organizations in the network. Main tel I want this organization to act for me for all steps of the appeal or fair hearing Signed NAME (print): Date of birth Medicaid or Plan ID Address Tel DATE: -24-

27 MLTC APPEAL REQUEST FORM FOR SERVICES BEING REDUCED, SUSPENDED, OR STOPPED Mail To: Date: Plan Name/UR AGENT] Fax: Address City, State Zip DEADLINE: If you want to keep your services the same until the Plan Appeal decision, you must ask within 10 calendar days of the date of this notice, or by the date the decision takes effect, whichever is later. (If you lose your appeal you may have to pay for services you got while waiting for the decision.) The last day to ask for a Plan Appeal to keep your services the same is [Notice Date+10]. You have a total of 60 calendar days from the date of this notice to ask for a Plan Appeal. The last day to ask for a Plan Appeal for this decision is [Notice DATE+60]. If you want a Plan Appeal, you must ask for it on time. Enrollee Information First Name Last Name Enrollee ID: Plan Reference Number Address: City, State, Zip Home Phone: Cell Phone: Type of Service being reduced, suspended or stopped: I think the plan s decision is wrong because: Check all that apply: I do NOT want my services to stay the same while my Plan Appeal is being decided. I request a Fast Track Appeal because a delay could harm my health. I enclosed additional documents for review during the appeal. I would like to give information in person. I want someone to ask for a Plan Appeal for me: Have you authorized this person with this plan before? YES NO Do you want this person to act for you for all steps of the appeal or fair hearing about this decision? You can let us know if change your mind. YES NO Requester (person asking for me): Name: E- mail: Address: City: State: Zip Code: Phone #: ( ) Fax #: ( ) Enrollee Signature: Date: Requester Signature: Date: If this form cannot be signed, the plan will follow up with the enrollee to confirm intent to appeal. -25-

28 MANAGED CARE DECISION FAIR HEARING REQUEST FORM AC MAIL TO: NYS Office of Temporary and Disability Assistance FAX TO: Office of Administrative Hearings Managed Care Unit P.O. Box Albany, New York DEADLINE: If you want to keep your services the same until the Fair Hearing decision, you must ask within 10 calendar days of the date of this notice, or by the date the decision takes effect, whichever is later. The last day to ask to keep your services the same is [Notice Date+10]. You have a total of 120 calendar days from the date of this notice to ask for a Fair Hearing. The last day to ask for a Fair Hearing is [DATE+120]. If you want a Fair Hearing, you must ask for it on time. I want a Fair Hearing. This decision is wrong because: Enrollee Name Signature Phone Representative (if any) Name Relationship Signature Phone Your service WILL NOT CHANGE until the Fair Hearing decision if you ask for a Fair Hearing by [date+10]. If you lose your Fair Hearing you may have to pay for services you got while waiting for the decision. Check this box only if you do not want to keep your health care the same: I DO NOT want to keep my health care the same. I agree that the plan can reduce, suspend or stop my services as described in this notice before my Fair Hearing decision is issued. MANAGED CARE DECISION FAIR HEARING REQUEST FORM Notice Date Effective date Service Type: Case Name (c/o, if present) and Address: MLTC/Managed Care Plan Name: ENROLLEE ADDRESS CIN: Plan Reference No.: A Plan Appeal was filed on DATE: Plan decided appeal by Final Adverse Determination dated: : Amount/type of service plan provided before: On DATE OF Initial Adverse Determination Notice, Plan proposed to reduce services to (Amount) starting on DATE. After the Appeal, by Final Adverse Determination NOTICE dated Plan decided to reduce services to starting on DATE -26-

29 Important Change for Medicaid Managed Care and MLTC Enrollees Appeals and Fair Hearing Rights What is changing on May 1, 2018? New federal Medicaid managed care rules will take effect in New York State. These rules change the way Medicaid managed care plans and Managed Long Term Care (MLTC) plans make decisions about health care services and how you can appeal decisions by your Plan. These rules change how and when you can ask the State for a Fair Hearing about plan decisions. Starting May 1, 2018, If your plan is reducing or stopping a service, and you want to keep your services the same, without being reduced while your case is appealed, you must first ask for a Plan Appeal and wait for the Plan s decision before asking for a Fair Hearing. If you think any other plan decision is wrong, you must first ask for a Plan Appeal and wait for the Plan s decision before asking for a Fair Hearing. What happens if the plan denies my request to approve a new service or a change in services? For some services, you have to ask the plan for approval before you get them. If the plan denies approval, it has 14 days to send you a written notice of its decision, called an Initial Adverse Determination. If your health is at risk, your plan must fast track your request and decide in 72 hours. The decision may take up to 14 days longer if the plan needs more information. If your plan covers prescription drugs, the plan must make decisions about your prescriptions in 24 hours. If you think your plan s decision about your health care is wrong, you can ask the plan to look at your case again. This is called a Plan Appeal. This change means you must first ask for a Plan Appeal before you ask for a Fair Hearing. You will have 60 days to ask for a Plan Appeal. What happens if the plan decides to reduce or stop a service I am getting now? The plan must send you a written notice called an Initial Adverse Determination at least 10 days before the date the plan will reduce or stop any of your services. If you want to keep your services the same, without being reduced while your case is appealed, you must first ask for a Plan Appeal within 10 days or by the date the decision takes effect, whichever is later. Your services will stay the same as they were, until there is a decision. If you lose your Plan Appeal, and don t win your appeal at the next level (a Fair Hearing), you may have to pay for the services you received while waiting for the decision. Can someone ask for a Plan Appeal for me? If you want someone, like your medical provider, a family member, or a representative to ask for the Plan Appeal for you, you and that person must sign and date the appeal request, or you must have authorized that person to request an appeal for you in the past, or authorize them to do so now. How do I request a Plan Appeal? You can request a Plan Appeal by completing and faxing, mailing and for some plans, ing the Appeal Request Form that came with the plan s Initial Adverse Determination Notice. The address, fax number and, for some plans, address should be printed on the Appeal Request Form. You can also call the Plan to request the appeal, but you need to confirm a request made by phone in writing, unless you ask your Plan Appeal to be fast tracked. Remember if the plan is reducing or stopping a Page 1 of 3-27-