MAP plans are required to submit templates for certain integrated notices to the Department for approval prior to use. Templates will only be accepted from the health plan and must include the plan's unique identifier on each page. A completed and signed coversheet must accompany each template submitted. Submit templates and coversheets to: mltc.docs@health.ny.gov

• MAP Integrated Notice Submission Coversheet - (PDF) - 01.02.2024
• Appeal Decision - (PDF) - 01.02.2024
• Appeal Decision Delay - (PDF) - 01.02.2024
• Coverage Determination - (PDF) - 01.02.2024
• Fast Complaint Letter - (PDF) - 01.02.2024

Model Notices for Medicaid Managed Long Term Care Plans (Partial and MAP)

Managed Long Term Care plans are required to submit templates for model notice types to the Department for approval prior to use. Templates will only be accepted from the health plan and must include the plan's unique identifier on each page. A completed and signed cover sheet must accompany each template submitted. Submit templates and cover sheets to: mltc.docs@health.ny.gov

• Model Notice Submission Coversheet - (PDF) - 1.2.2024
• Complaint Appeal Resolution Notice - (Web) - (PDF) - 11.4.2021
• Complaint Resolution Notice - (Web) - (PDF) - 11.4.2021
• Extension Notice - (Web) - (PDF) - 11.4.2021
• Final Adverse Determination
  • Denial Notice - (Web) - (PDF) - 11.4.2021
  • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021
• Initial Adverse Determination
  • Denial Notice - (Web) - (PDF) - 11.4.2021
  • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021
• Approval Notice - (Web) - (PDF) - 11.20.2017

• Template Notice Submission Coversheet - (PDF) - 01.02.2024
• Nursing Home Enrollee Intent to Disenroll Notice - (Web) - (PDF)
• Involuntary Disenrollment - Intent to Disenroll Notice - (Web) - (PDF)
• Electronic Notice - (PDF)

• Reasonable Effort Policy - (Web) - (PDF) - 4.17.23
• Guidance for Required Changes to Medicaid Model Notices About Service Authorization and Appeals under 42 CFR 438 - (Web) - (PDF) - November 4, 2021
• 2016 Final Rule FAQs About Service Authorization and Appeals under 42 CFR 438 - (Web) - (PDF) - January
• New York State Medicaid Managed Long Term Care Enrollee Right to Fair Hearing and Aid Continuing for Plan Service Authorization Determinations
• New York State Medicaid Managed Long Term Care Service Authorization and Appeals Timeframe Comparison
• New York State Medicaid Managed Long Term Care Grievances Timeframe Chart

• 42 CFR 438 MMC Service Authorization and Appeals - Partial, MAP, MA
  • Presentation - December 7, 2017