Appeals & Hearings - NY Health Access

Appeals & Hearings

Medicaid Fair Hearings in NYS - Common Links and Changes - CALL-In Hearings Started May - Roll out Schedule Changed

Introduction and Updates Medicaid recipients have the right to request a Fair Hearing to appeal an adverse action. This includes decisions made by a managed care or Managed Long Term Care plan, by the local Dept. of Social Services ("LDSS") or by NYS's contractor, NY Medicaid Choice or the NY...

Right to a "Home Hearing" under Varshavsky Case - Special Rights in Fair Hearings Seeking Increases in Medicaid Home Care

This article can also be downloaded as a Fact Sheet here. INTRODUCTION Individuals who, because of mental or physical disabilities, cannot travel to a fair hearing without substantial hardship or medical detriment, have rights under an injunction in a class action called Varshavsky. Read...

NYS OTDA "CALL-IN" Phone Hearing Pilot -- Being Phased In by County in 2026

Introduction - What is the Call-In Phone Hearing Pilot? The Office of Temporary and Disability Assistance’s (OTDA) Office of Administrative Hearings (OAH) started a new pilot program for telephonic fair hearings in 2026. Under the new process, appellants residing in identified counties and their...

Requesting a New or Increased Service from a Medicaid Managed Care or MLTC

Introduction and News Alerts Members of Medicaid Managed Care plans, including Managed Long Term Care (MLTC) plans, have the right to request a new service or more of the same service they already receive. This article explains the rules about when the plan must make a decision on these requests....

Appeals & Grievances in Managed Long Term Care & Managed Care

Since May 1, 2018 - Member Must Request Internal "Plan Appeal" before requesting a Fair Hearing In 2016, CMS adopted changes in federal Medicaid managed care regulations requiring "exhaustion" of Plan Appeals prior to requesting a Fair Hearing. These changes became effective in NYS in MAY 2018. ...

Medicaid Advantage Plus "MAP" - Changes in Integrated Appeals & Hearing Process - Jan. 1, 2026

Introduction and NEWS ALERTS - Change in MAP Appeals Process starting Jan. 1, 2026 2025 UPDATE - The integrated appeal and fair hearing process launched in 2020 for members of Medicaid Advantage Plus (“MAP”) plans was phased out to end December 31, 2025. Now there is a new bifurcated appeal...

Getting Help with Managed Long Term Care and Other Types of Medicaid Managed Care

Here are organizations where you can seek help for problems with Medicaid Managed Long Term Care (MLTC) plans, Medicaid Advantage Plus (MAP) plans, and Mainstream plans. Also see these KNOW YOUR RIGHTS Fact Sheets about MLTC and related topics STATEWIDE ICAN –...

Grievance and Appeal Contacts for Managed Long Term Care Plans

SINCE MARCH 1, 2018, members of Medicaid Managed Care and Managed Long Term Care plans will be required to request an INTERNAL APPEAL within their plan, and wait until the plan decides that appeal before they may request a FAIR HEARING when they receive an Initial Adverse Determination denying or...

Health Plan Appeal Rights in New York After the Affordable Care Act

Samuel Salganik, an attorney at Community Health Advocates of the Community Services Society (CSS) wrote this incredibly thorough article breaking down the types of appeal rights available to individuals covered by the various types of private health insurance plans in New York. This article...

Medical Records Must be Provided FREE if Needed to Support Claims for Public Benefits - New September 2017

In September 2017, a new law went into effect that requires health care providers to provide medical records at no charge, when needed to support an application, claim or appeal for a government benefit or program. Here's what the law adds to Mental Hygiene Law § 331 and NYS Public Health Law §...

What You Need to Know About Medicaid and Fair Hearings

By the Legal Aid Society Medicaid is a comprehensive health insurance program for low-income people of all ages. Medicaid covers a variety of health services including home care, nursing home, dental, vision, crisis intervention, inpatient rehabilitation, outpatient services, opioid treatment...

2025 Medicaid Fair Hearing Compliance Plan = "Pre-Hearing Dispositions" or PHD's

In New York, there are over 10,000 Medicaid fair hearings pending past the 90-day deadline. The backlog grew significantly during the COVID-19 Public Health Emergency and is the largest in the nation. To address the backlog and avoid corrective action, the Department of Health (DOH) announced a...