MLTC Model Notice FAQ

Partial Capitation Model Action Notices
Frequently Asked Questions (FAQs)
May 29, 2015

These FAQs respond to questions received by the Partial Capitation Model Action Notices. Please consult all previously released materials in conjunction with the following FAQs. If you have any questions regarding this information, please email to the following address: mltcworkgroup@health.ny.gov

General Questions

Q1. What services are eligible for Aid Continuing?

A1. Aid Continuing must be provided in all cases where timely notice is required by 18 NYCRR 358-3.3.

Q2. Is the State sending out Announcement letters or Plans?

A2. The Division of Long Term Care released a template announcement letter on May 28, 2015. Plans must use this notice to inform their enrollees about the changes to fair hearing, Aid to Continue, and action notice policies.

Q3. Can an enrollee request an Internal Appeal and a Fair Hearing at the same time?

A3. Yes. The enrollee can file an Internal Appeal and/or a Fair Hearing at any time within their respective deadlines. This means that the enrollee could pursue both at the same time.

Q4. Who receives and processes fair hearing requests?

A4. The Office of Temporary and Disability Assistance (OTDA).

Q5. How should plans resolve differences between the model notices and the MLTC Partial Capitation contract?

A5. Plans should abide by the timelines and policies indicated on the model notices, and as described in this FAQ. The Department is addressing inconsistencies with the model contract.

Q6. Can the State provide the final language to be used to replace the statement "You have [60 working days] from the date of this notice to ask for an Internal Appeal"?

A6. Plans must the following language on the Model Initial Adverse Determination (IAD) notice:

"You have 60 working days from the date of this notice to ask for an Internal Appeal."

Q7. What is the implementation date for the model notices?

A7. The new model notices must be used for actions on or after July 1, 2015.

Q8. When do the new Aid to Continue and other new policies go into effect?

A8. The new policies and procedures that accompany the utilization of the new model notices apply to actions on or after July 1, 2015.

Q9. For provider claim denials, is it acceptable to add template language to existing EOBs, instead of using the IAD?

A9. No. For provider claim denials, plans must send the Model IAD and the 4687 Action Taken notices to the member.

Q10. Does the checkbox guidance for the 4688 Action Taken notice for Medicaid Managed Care apply to MLTC and the 4687 Action Taken notice? If the plan´s system cannot accommodate selection of pre-printed choices, then can the specific action appear alone?
For example: "ABC Health Plan has made a decision about your health care service. On 07/06/15 this health care service: Personal Care Level 2 will be reduced."

A10. Yes. If the plan´s system cannot accommodate selection of pre-printed choices, the plan may comply by showing the correct action on each generated notice as a line of text.

Q11. Are plans responsible for translating the notices into prevalent languages?

A11. Yes, plans must translate the notices into prevalent languages.

Q12. Which version of the notices released by the Department should the plans use?

A12. Plans should utilize the most recent template notices approved by the Department, distributed by plan managers starting the week of May 11, 2015. Any approval of the model notices submitted by the plans will be limited to use for actions that occur on or after July 1, 2015.

Q13. Where can we find the April 29 webinar video and slides?

A13. The April 29 webinar and slides have been uploaded to the MRT 90 webpage: https://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm

Webinar:
https://www.health.ny.gov/health_care/medicaid/redesign/docs/2015-04-29_new_model_initial_determination_and_model_action_notices.wmv
Slides:
https://www.health.ny.gov/health_care/medicaid/redesign/docs/mltc_model_notice_training_april-29.pdf

Q14. How should plans submit the notices for review?

A14. Plans should send the notice to their plan manager at the Department, and copy mltcworkgroup@health.ny.gov.