Notice to Reduce, Suspend or Stop Services

MODEL MMC/MLTC FINAL ADVERSE DETERMINATION (WITH AC) (Revised 11/17)

  • Notice also available in Portable Document Format (PDF)

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MCO/MLTC OR DUAL LETTERHEAD FOR PLAN AND UR AGENT/BENEFIT MANAGER]
[Plan Name] [UR AGENT/Benefit Manager Name]
[Address]
[Phone]

FINAL ADVERSE DETERMINATION
NOTICE TO REDUCE, SUSPEND OR STOP SERVICES

[Date]

Enrollee]
[Address]
[City, State Zip]

Enrollee Number: [ID number or CIN]
Coverage type: [coverage type]
Plan Reference Number: [plan reference number]
Provider: [provider to perform the service]
Facility: [Insert Facility:]
Service developer/manufacturer: [service developer/manufacturer]]

Dear [Enrollee]:

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 [Date*120]. If you want to keep your services the same until your Fair Hearing is decided, you must ask for a Fair Hearing by [DATE*10]. 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: [1–800–MCO–PLAN].

Why am I getting this notice?

You are getting this notice because on [date appeal filed] {for Fast Track appeals insert} [at [hour received]], you or your provider asked for a Plan Appeal about our decision to [reduce] [suspend] [stop] [service]. [Insert summary of appeal].

On [date of appeal determination], [[UR Agent Name/Benefit Manager] on behalf of] [Plan Name] decided we are [not changing our decision][changing our decision and will partially approve your service].

From [STARTDATE] to [ENDDATE], the plan approved: [HOURS/DAYS, VISITS, LEVEL, QTY, etc., and PREVIOUS TOTAL AMOUNT]

On [DATEIAD], we decided to [reduce your [SERVICE] from [HOURS/DAYS, VISITS, LEVEL, QTY, etc.] to [HOURS/DAYS, VISITS, LEVEL, QTY, etc.] starting on [Date].] {or} [suspend your [SERVICE] from [STARTDATE] to [ENDDATE].] {or} [stop your [SERVICE] on [Date].]

On [DATE FAD], we have [partially] denied your Plan Appeal and:

          [On [EFFDATE] we will reduce your [SERVICE] to [HOURS/DAYS, VISITS, LEVEL, QTY, etc. and new TOTAL AMOUNT].] {or}
          [On [EFFDATE] we will suspend your [SERVICE] from [STARTDATE] to [ENDDATE].]
{or}
         [On [EFFDATE] we will stop your [SERVICE].]

{Insert as applicable} [We will review your care again [IN TIME FRAME/ ON DATE].]

{Insert for continuing services}[This service will be provided by [a participating][an out of network] 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 [reduce][suspend][stop] your service?

We made this decision because the [service is not medically necessary][there was not enough information to determine if the service is medically necessary][other decision].

  • Your [service] will be [reduced][suspended][stopped] because:
    • [Indicate the change in the enrollee´s medical condition, social, or environmental circumstances since the previous authorization was made.]
    • [State when the change occurred.]
    • [Include the criteria requirements and other information relied on to make the decision.]
  • You no longer meet the criteria for your current level of service because:
    • [Describe why or how the change in medical condition, social, or environmental circumstances no longer meet the criteria for the previous authorization or why/how this change necessitates a change in services.]

{{Note: The rationale must be sufficiently specific to enable the enrollee to determine the basis for appeal.}

This decision was made under 42 CFR Sections 438.210 and 438.404; NYS Social Services Law Sections 364–j(4)(k) and 365–a(2); 18 NYCRR Section 360–10.8; [ADD SPECIFIC BENEFIT CITATION AS APPLICABLE]

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.
  • {Insert if applicable} [If we said your service was not medically necessary, you can ask the State for an External Appeal – this is 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 [date+10].
  • 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 [date+120].

How can I ask for a Fair Hearing?

To ask for a Fair Hearing, you can:

  • Call: 1–800–342–3334 (TTY call 711 and ask operator to call 1–877–502–6155)
  • Request online using the form at: http://otda.ny.gov/oah/FHReq.asp
  • 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 22023
      Albany, New York 12201–2023

      FAX FAIR HEARING REQUEST FORM To: 518–473–6735
OR
  • WALK IN – New York City Only:
    • Office of Temporary and Disability Assistance
      Office of Administrative Hearings
      14 Boerum Place –
      1st Floor Brooklyn, New York 11201

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 www.LawhelpNY.org In New York City, call 311.

After the hearing, you will be sent a written decision about your case.

{Insert as applicable}[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 1–800–400– 8882 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 MMC}[1–800–206–8125] {or for MLTC} [1–866–712–7197]

{Insert for MLTC/LTSS/HARP Services or Delete}[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: 1–844–614–8800 (TTY Relay Service: 711)
Web: www.icannys.org | Email: ican@cssny.org]]

You can call [CONTACT PERSON NAME] at [PLAN NAME] at [1–800–MCO–PLAN] if you have any questions about this notice. {Insert as applicable} [To talk to someone at [UR Agent] call [contact name] at [UR Agent Number].]

Sincerely,

[MCO/UR AGENT/BENEFIT MANAGER Representative]

Enclosure:    Managed Care Fair Hearing Request Form
                        External Appeal Standard Description and Application

cc:                   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:
                           [Fname Lname]]


{MMC}[229]{or}[266]{MLTC}[212]{or}[211] MANAGED CARE DECISION FAIR HEARING REQUEST FORM AC

MAIL To:
NYS Office of Temporary and Disability Assistance
Office of Administrative Hearings
Managed Care Unit
P.O. Box 22023
Albany, New York 12201–2023

FAX To: 518–473–6735

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 [Date+10].
  • You have 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

    Signature

    Relationship

    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.
    FOR NYS OTDA ONLY     MANAGED CARE DECISION FAIR HEARING REQUEST FORM
    Notice Date [DATE] Effective [DATE] Service Type:[Service]
    Case Name (c/o, if present) and Address:

    [ENROLLEE NAME
    ENROLLEE ADDRESS
    ]


    CIN: [MEDICAID CIN]


    [MCO/URA NAME
    MCO/URA ADDRESS
    ]


    Reference No.: [MCO REFERENCE NUMBER]
    A Plan Appeal was filed on [date]. On [date of appeal determination], [UR Agent Name/Benefit Manager] on behalf of][Plan Name] decided we are [not changing our previous decision to [reduce][suspend][stop]] [changing our previous decision and will partially approve] the service.
    From [STARTDATE] to [ENDDATE], the plan approved: [HOURS/DAYS, VISITS, LEVEL, QTY, etc., and PREVIOUS TOTAL AMOUNT]
    On [DATEIAD], we decided to [reduce your [SERVICE] from [HOURS/DAYS, VISITS, LEVEL, QTY, etc.] to [HOURS/DAYS, VISITS, LEVEL, QTY, etc.] starting on [Date].] {or} [suspend your [SERVICE] from [STARTDATE] to [ENDDATE].] {or} [stop your [SERVICE] on [Date].]
    On [EFFDATEFAD] we will reduce your [SERVICE] to [HOURS/DAYS, VISITS, LEVEL, QTY, etc. and new TOTAL AMOUNT].]{or} [on [EFFDATE] we will suspend your [SERVICE] from [STARTDATE] to [ENDDATE].] {or} [on [EFFDATE] we will stop your [SERVICE].]

    NOTICE OF NON–DISCRIMINATION

    [PLAN NAME] complies with Federal civil rights laws. [PLAN NAME] does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex.

    [PLAN NAME] 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 [PLAN NAME] at <toll free number>. For TTY/TDD services, call <TTY>.

    If you believe that [PLAN NAME] 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 [PLAN NAME] by:

    Mail:             [ADDRESS], [CITY], [STATE] [ZIP CODE],
    Phone:        [PHONE NUMBER] (for TTY/TDD services, call <TTY>)
    Fax:              [FAX NUMBER]
    In person:   [ADDRESS], [CITY], [STATE] [ZIP CODE]
    Email:         [EMAIL 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 https://ocrportal.hhs.gov/ocr/portal/lobby.jsf
    Mail:               U.S. Department of Health and Human Services
                           200 Independence Avenue SW., Room 509F, HHH Building
                           Washington, DC 20201
                           Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html
    Phone:          1–800–368–1019 (TTY/TDD 800–537–7697)

    ATTENTION: Language assistance services, free of charge, are available to you. Call <toll free number> <TTY/TDD>. English
    ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al <toll free number> <TTY/TDD>. Spanish
    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>. Chinese
    ملحوظة: إذا كنت تتحدث اذكر اللغة، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان. اتصل برقم toll free numberوالبكم الصم هاتف رقم<TTY/TDD>. Arabic
    주의 : 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다<toll free number> <TTY/TDD> 번으로 전화해 주십시오. Korean
    ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните <toll free number> (телетайп: TTY/TDD). Russian
    ATTENZIONE: In caso la lingua parlata sia l´italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero <toll free number> <TTY/TDD>. Italian
    ATTENTION: Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le <toll free number> <TTY/TDD>. French
    ATANSYON: Si w pale Kreyòl Ayisyen, gen sèvis èd pou lang ki disponib gratis pou ou. Rele <toll free number> <TTY/TDD>. French Creole
    אויפמערקזאם: אויב איר רעדט אידיש, זענען פארהאן פאר אייך שפראך הילף סערוויסעס פריי פון .toll free number/TTY/TDD< רופט .אפצאל Yiddish
    UWAGA: Jeżeli mówisz po polsku, możesz skorzystać z bezpłatnej pomocy językowej. Zadzwoń pod numer <toll free number> <TTY/TDD> Polish
    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>. Tagalog
    লক্ষ ্য করুনঃ যদি আপদন বাাংলা , কথা বলতে পাতেন , োহতল দনঃখেচায় ভাষা সহায়ো পদেতষবা উপলব্ধ আতে । ফ ান করুন ১ -<toll free number> <TTY/TDD> Bengali
    KUJDES: Nëse flitni shqip, për ju ka në dispozicion shërbime të asistencës gjuhësore, pa pagesë. Telefononi në <toll free number> <TTY/TDD>. Albanian
    ΠΡΟΣΟΧΗ: Αν μιλάτε ελληνικά, στη διάθεσή σας βρίσκονται υπηρεσίες γλωσσικής υποστήριξης, οι οποίες παρέχονται δωρεάν. Καλέστε <toll free number> <TTY/TDD>. Greek
    ںیرک لاک ۔ ںیہ بایتسد ںیم تفم تامدخ یک ددم یک نابز وک پآ وت ،ںیہ ےتلوب ودرا پآ رگا :رادربخ <toll free number> <TTY>. Urdu