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 process.   See the DOH MAP Integrated Hearings Phase-out plan here. 

• The type of appeal process used in 2026 depends on when the MAP member requested the service that the appeal is about.

  1. If the service was requested before Dec. 31, 2025, the "integrated appeal" system is used - described below.  The last day for a member to request a plan appeal of a denial using this system is April 19, 2026. 

  2. If the service was requested on or after  January 1, 2026, there is a new bifurcated appeals and grievance processes for Medicare and Medicaid.  The initial plan determination and "Level I" Plan Appeal will be the same as they were before, described below..  The big change comes after that Level 1  Plan Appeal decision -- the change is in the Level 2 appeal.  See below. At tthat stage, issues regarding MEDICAID are appealed through the regular NYS Fair Hearing process, while MEDICARE issues are appealed through the Medicare appeals pathway described here on page 8. 

     • Also see the model Member Handbook insert  (at pages 4-6 of link) explaining the change that plans were required to send to members. 

• See NYLAG's comments about the DOH MAP Phase-Out Plan here.

• CMS webpage about D-SNPs: Integration & Unified Appeals & Grievance Requirements.  Scroll down to the bottom of the webpage to this heading Unified Appeals and Grievances.  

What are Medicaid Advantage Plus (MAP) plans

Differences between a MAP and MLTC plan

MAP plans are composed of two  "aligned" plans that together provide all Medicare and Medicaid services.  The plans are:

1. For MEDICARE  - The plan is a "D-SNP" -- a type of a  Medicare Advantage plan that is a Special Needs Plan (SNP) exclusively available to Dual Eligibles (people with Medicare and Medicaid).  Even within D-SNP plans (Dual-SNP) there are different types.  The only type of D-SNP that can be "aligned" with a MAP plan - is a "FIDE-SNP"  (Fully Integrated Dual Eligible - Special Needs Plan).  This FIDE-SNP covers the Medicare services.    Some other Dual-SNPs are not fully integrated, meaning they may cater to people with Medicare and Medicaid but are not combined Medicare/Medicaid plans integrating both benefit packages.  See inforrmation about other types of D-SNPs here -- "CO" and "HIDE" D-SNPs..

2.  For MEDICAID -  a Medicaid Advantage Plus (MAP)  plan provides all Medicaid services, including those that would otherwise be provided by a Managed Long Term Care (MLTC) plan.  The Medicaid services are beyond what an MLTC plan provides, because it also includes primary and acute care, hospital deductibles and coinsurance, and all other Medicaid services.  

In a MAP plan, both the above Medicare and Medicaid plans are "aligned," meaning they are operated by the same insurance company and are contracted to work together.   These MAP plans are also called  “Fully Capitated” plans.  "Capitation" is the monthly premium a plan receives from the government to provide a package of services.   "Full capitation" means that the aligned plans receive a monthly "capitation" premium from both the federal and state government to provide ALL Medicare and Medicaid services. 

Regular Managed Long Term Care (MLTC) plans  have   "Partial capitation"  - meaning their capitation covers only some but not all Medicaid services, and covers NO Medicare services.  Members of MLTC plans have their Medicare coverage separate – they can choose to have Original Medicare or Medicare Advantage. 

PROVIDER NETWORKS -   The member must use only providers that are in the plans' provider network.  In MAP plans,  this is true for Medicare and Medicaid providers. In MLTC plans, the member must use in-network providers for home care, dental and other services covered by the MLTC plan; but their choice of providers for Medicare services depends on their choice of Medicare model.  

• If they choose Original Medicare, they may use any provider who accepts Medicare.  There is no "provider network."  They must also enroll in a Part D prscription drug plan.   However, for their MLTC services they must use providers in the MLTC plan's network. 

• If they choose Medicare Advantage, they must use providers in their chosen plan's network.  Some Medicare Advantage plans are Preferred Provider Organizations (PPO) and allow using providers out of network, usually at a higher out-of-pocket cost.  

See helpful info on ICAN website  --What kinds of MLTC plans are there?   

Medicare Rights Center has created a toolkit with resources about MAP benefits, consumer rights and appeals.  On that webpage you will find links to fliers:

• MAP consumer factsheet
• MAP advocate factsheet
• Important long-term care definitions
• Coverage options for dually eligible New Yorkers FAQ
• Medicaid Advantage Plus (MAP) appeals  (not yet updated since Integrated Appeals ended 12/31/2025) 

WHERE ARE MAP PLANS BY IN NYS - and How Many are Enrolled?

For a list of MAP plans in your area, go to https://www.nymedicaidchoice.com/choose/find-long-term-care-plan  and enter your county or for lists of plans by area go to the NY Medicaid Choice website at  https://nymedicaidchoice.com/program-materials and scroll down to HEALTH PLAN LISTS and then to Long Term Care Plans in your area.   

Also see the DOH webpage on Integrated Care Plans for Dual Eligible New Yorkers. Click on the dropdown for  Integrated Plan Offerings - 2026 to see a table titled Integrated Benefits for Dually Eligible Program (IB-Dual) Offerings - 2026.  In that chart:

• the third column shows the PRODUCT TYPE.  "MAP" indicates a MAP plan. 
• the second column shows the Medicare D-SNP plan number (ie H8432 (041)) and 
• fourth  column shows  the Service Area -- which is the counties the MAP plan operates in.    

• WARNING - MAP and D-SNP PLAN NAMES ARE CONFUSING!!   Most MAP plans are operated by insurance companies that also operate MLTC partially capitated plans and other plans, such as Medicare Advantage plans.  It can be difficult to tell one from the other.  The lists at the links above show that they have slightly different names.  When you ask your client what plan they are in, it is not enough to say "VNS HEALTH" since that company operates an MLTC ("VNS CHOICE")  and a MAP plan ("VNS CHOICE TOTAL"). All of these companies  also operate Medicare Advantage plans.  

List of all NYS Special Needs Plans (SNP)  2026 (SNP)   -- has separate tab for each of the 3 basic types of  SNPs.   Only FIDE SNPs can be part of a MAP plan - not HIDE or CO D-SNPs. 

HOW MANY NEW YORKERS ARE IN MAP PLANS?  And Where are the MAP Plans?

There are nearly 78,000  people in MAP plans as of February 2026  – all but about 8,000 of those are in NYC.  See DOH monthly enrollment stats (Download document for most recent month -- Tab named  Medicaid Advantage Plus shows  number enrolled in each plan in NYC and in each county).

This is compared to  about 285,750 in regular MLTC plans.  

In 2024, a law was passed required companies that sponsored MLTC plans to also offer a MAP plan.  This has led to more MAP plans.   

Find lists of MAP Plans here. with counties covered.

PACE Plans are a different  "FULLY CAPITATED PLAN"  like MAP plans

PACE plans are "fully capitated plans like MAP plans and also are only for people who need Medicaid long term care services, and the plans cover all Medicare and Medicaid services.  Three are only 9,876  New Yorkers in PACE plans in Feb. 2026.  See DOH monthly enrollment stats (download most recent document -- On tab for Managed Long Term Care look at the TOP for PACE enrollment -  number enrolled in each plan in NYC and in each county). 

The FIDA program was similar to MAP, but was a demonstration program that closed at the end of 2019.   

For MAP members who request a new or increased service, the initial steps are not changing in the new Bifurcated Appeal System in 2026.

1. First, they make the request for the new or increased service -- whether a Medicaid or Medicaid service.
   See this article on best practices for these requests. 

2. Initial adverse notice  --"Coverage Determination Notice" or "Coverage Decision Letter" 

If that request for an increase in services or a new service is denied, the MAP plan must issue a "Coverage Determination Notice"   or Coverage Decision Letter. 

• TEMPLATE for notice - From CMS webpage  under Unified Appeals and Grievances-  "CMS released the revised 2025 Coverage Decision Letter (ZIP) in English and Spanish for Applicable Integrated Plans. Please refer to the accompanying OMB-Approved Applicable Integrated Plan Coverage Decision Letter Memorandum (PDF) that announced the release on January 6, 2026. Plans must begin using the updated Coverage Decision Letter on March 6, 2026."

•  Compare the name of MLTC Notice -- called "Initial Adverse Determination" or IAD - Model denial IAD and  Model reduction IA

• Which services? The MAP plan issues this Coverage Determination Notice for both Medicare and Medicaid services covered by the plan EXCEPT for prescription drugs covered by the MAP plan.  

3. Request Level One Appeal -  This is also known as the "internal appeal" or the "plan appeal."  

The member must request this appeal, in which plan staff internally review the initial denial and either reverse it or affirm it.  In both MAP and MLTC, “exhaustion” of this plan appeal is required first before requesting  a fair hearing.  See more on MLTC appeals and 'exhaustion" here. 

• If the plan's inital Coverage Determination Notice is a REDUCTION or TERMINATION of services, the member has the right to Aid Continuing if the appeal is requested before the Effective Date of a proposed reduction -(NOTE 15-day advance notice required of a reduction - not the usual 10-day advance notice for other Medicaid and MLTC reductions.)  This is in the Memorandum of Understanding between CMS and NYS DOH  Section  3.2.2.3 (P. 10 of the PDF) that governs MAP hearings. 

• Which services? The requests the appeal in the same way whether the appeal involves denial or reduction of  Medicare or Medicaid services covered by the plan, EXCEPT for prescription drugs covered by the MAP plan.

3. Plan DENIES Level One Appeal - New Bifurcated Appeal System Starting Jan. 1, 2026

• Plan Notice Denying Internal Plan Appeal - has different names from an MLTC notice

  • MAP notice is a "Appeal Decision Notice"  or  Appeal Decision Letter (ZIP) in English and Spanish    From CMS site: "For more information on these notices, please see the November 20, 2020 CY 2021 D-SNP Integrated Notices Memorandum (PDF)."​​​​​​​

  • Compare MLTC Notice denying a Plan Appeal is Called "Final Adverse Determination" or FAD -  Model Denial FAD  and  Model Reduction FAD  -

Level 2 Appeal -  If the denied service is a MEDICAID service - Request Fair Hearing

• ​​​​​​​​​​​​​​The member's next step is to request a NYS Fair Hearing with the NYS Office of Temporary & Disability Assistance.   

• If the action is a threatened reduction or termination of a service, member must request the hearing in time to get Aid Continuing - before the Effective Date of the reduction.  This effective date must be at least 10 days after the date of the notice. 

• ​​​​​​​Members have the same rights to request a Fair Hearing and in the hearing process as in MLTC.  See this article  about MLTC member  rights to request fair hearings. 

  • Also see this article about rights to submit and obtain evidence, and recent changes in Fair Hearings in NYS and other fair hearing information. 

• Before Dec. 31, 2025, MAP members did NOT have to request a Fair Hearing if they lost the "Plan 1 appeal."  The plan automatically forwarded the case to the "integrated hearing" office.  These integrated hearings ENDED. Now the hearing must be requested by the member.  

•  Rights under Varshavsky case if MAP Member is "Homebound":  ​​​​​​​

​​​​​​​Starting Jan. 1, 2026, members of MAP plans have the same rights as MLTC members under a class action called Varshavsky v. Perales.  That decision held that Medicaid recipients who cannot travel to a hearing without substantial hardship because of a disability have the right to a hearing held in their home,  if an initial hearing held by phone is not decided fully favorably.   The State took the position that Varshavsky did not apply to former system of Integrated MAP  hearings that ended in 2025.  However, now that MAP members use the same hearing system as MLTC members, they can now benefit from  two important benefits of Varshavsky. See Varshavsky article  for more about these benefits. 

• First, for members certified to be in the protected class, a decision after a phone hearing can only be issued if it is fully favorable.  If it is not fully favorable, the decision cannot be issued, and the case must be scheduled for an in-home hearing. 
• Second,  in any case where the appellant is classified as "homebound,"  45 days after the hearing was requested,  NYS OTDA orders interim relief.  If the issue of the hearing was denial of an increase in Medicaid personal care or CDPAP services, the interim relief, sometimes known as "Varshavsky Aid Continuing"  requires the plan (or HRA/DSS if that's who denied the increase) to temporarily increase the care to the amount requested, until the home hearing is held and decide.  This interim relief is also ordered in the first situation above, where the "phone hearing" cannot be decided fully favorably, and the case is scheduled for an in-home hearin

 OPTION to Request an External Appeal with the NYS Dept. of Financial Services - in addition to Fair Hearing

• ​​​​​​​After receiving the Level I Plan Appeal Decision notice, the member has the option to request an External Appeal from NYS Dept. of Financial Services.  See this article about MLTC appeals for more information, including the right to request the External Appeal on an expedited basis.   If the "expedited" external appeal track is used, a decision may be issued in a matter of days - much faster than a fair hearing.  If the external appeal decision is favorable, it is binding on the plan, and the fair hearing request may be withdrawn.  
• REMINDER- Requesting an External Appeal does not stop the clock for requesting a Fair Hearing.  The member must be mindful of the deadline to request a Fair Hearing.  (We think it's 60 days but are not sure since it is only starting this year  2026 that MAP hearings must be requested by the member).  Stay tuned.  
• If there is both an External Appeal decision and a Fair Hearing decision, the Fair Hearing decision controls.  
• External appeals may only be used if the denial was based on lack of medical necessity, but this is generally the issue in these appeals.  The appeals are solely on paper so strong documentary evidence is needed.  
• If the external appeal is decided adversely, the enrollee still may do the fair hearing.  Since these take a long time to schedule, it is recommended to request the fair hearing first, then file and pursue the External Appeal while the Fair Hearing is pending.
• See more about these external appeals here.  The State DFS External Appeal website is here.  

​​​​​​​Level 2 Appeals and Later Appeals if the Service is a MEDICARE service.

The notices and procedures to appeal are very different if the service is solely covered by Medicare and not Medicaid.  See this graphic describing the process, from these CMS Integrated Care Resources Center,  Technical Assistance Tool,  Appeals and Grievances: Comparisons of Existing and New Integrated Processes for Individuals Enrolled in Applicable Integrated Plans  page 8 (updated June 2022).  Note that the graphic below does not mention the option of an External Appeal for Medicaid services discussed above. 

CMS has a form  Appeal Decision Letter (ZIP) in English and Spanish for Applicable Integrated Plans that the Plan must issue after a Level 1 appeal is denied.  This notice attempts to explain the different appeal paths for Medicare and Medicaid services  (this is posted on this CMS webpage under Unified Appeals and Grievances). 

References about the Bifurcated Appeals System

• Federal regulations - 42 C.F.R. 422.633, amended on Jan. 19, 2021, as part of  new requirements applicable to certain Integrated  Dual Eligible Special Needs Plans.  See 86 FR 6103.  See also 45 CFR § 422.2267(e).

• State Medicaid Agency Contract (SMAC) CY 2026 - (PDF)

  • State Medicaid Agency Contract (SMAC)  FAQ for 2026  (2025) (Web) - (PDF)​​​​​​​

  • State Medicaid Agency Contracts Submission Requirements for Contract Year 2027 (PDF) outlines the requirements for review of State Medicaid Agency Contracts (SMACs) for contract year 2027. Submissions will be due July 6, 2026.

• DOH MAP Integrated Hearings Phase-out plan. 

• CMS webpage about D-SNPs: Integration & Unified Appeals & Grievance Requirements.  Scroll down to the bottom of the webpage to this heading Unified Appeals and Grievances.  There are posted model notices: 

  • ​​​​​​​​​​​​​​CMS released the revised 2025 Coverage Decision Letter (ZIP) in English and Spanish for Applicable Integrated Plans. Please refer to the accompanying OMB-Approved Applicable Integrated Plan Coverage Decision Letter Memorandum (PDF) that announced the release on January 6, 2026. Plans must begin using the updated Coverage Decision Letter on March 6, 2026."

  • Appeal Decision Letter (ZIP) in English and Spanish  

  • Frequently Asked Questions on Coordinating Medicaid Benefits and Dual Eligible Special Needs Plans Supplemental Benefits (PDF)

  • The same CMS webpage has links by state -- for New York for Applicable Intgegrated Plans (AIP):

    • CY 2026 New York AIP D-SNP Model Material Memo (PDF)

    • CY 2026 New York AIP D-SNP Model Material (DOCX)(Model Language for Member Handbook - Summary of Coverage)​​​​​​​

ARCHIVE: Integrated MAP Appeal Process - from 2020 - Dec. 31, 2025

The  Integrated Appeal process essentially continued the integrated procedure that was used in the FIDA demonstration program, that ended  Dec. 31, 2019.  OTDA calls it "FIDE-SNP" appeals - Fully Integrated Dual Eligible - Special Needs Plan.  The steps through the Level 1 Appeal were the same as they are now, described above.  The difference was after the plan denied the Level 1 Appeal with an adverse Appeal Decision.

1. LEVEL 2 APPEAL - Request for Hearing  was Automatically Made for Member for both Medicare and Medicaid Services

• ​​​​​​​MAP "FIDE" Hearings - were held by the Integrated Administrative Hearings Office (IAHO), which is administered by NYS OTDA through a separate system than regular Medicaid fair hearings.  The procedures and timing requirements for  the IAHO hearings are in the Memorandum of Understanding (MOU) between the NYS Dept. of Health and CMS that governs the integrated hearings demonstration.   

  • 1. Within 2 business days after its adverse Appeal Decision, the plan must  AUTOMATICALLY forward the case  and the case file to the IAHO, which serves as the request for the hearing.  MOU Appendix 3,  Section 3.4.1.1. The MAP member does NOT have to request this hearing.  

       • It is this action that Healthfirst MAP plan failed to do for 789 members.  See March 2021 News Alert above to read about how this mistake is being remedied for these members.  

    2. Within 14 calendar days of forwarding the administrative record  to the IAHO, the plan must send the member an Acknowledgement of Automatic Administrative Hearing and Confirmation of Aid Status with a copy to the IAHO. MOU Appendix  3, Section 3.4.4.; 3.5.1. The notice should advise the member that if the do not hear from OTDA about scheduling the hearing within 10 days (24 hours for expedited appeals), the member should call the IAHO. 

    3. OTDA is supposed to send the member and plan notice of the hearing 10 days in advance.  MOU Appendix 3, Section 3.5.2.

2. LEVEL 3 APPEAL - Appeal to the Medicare Appeals Council.
   Even though the issue may be about MEDICAID not Medicare (such as a denial of an increase of CDPAP) - the next appeal is to the Medicare Appeals Council in integrated hearings.

3. Level 4 APPEAL - Appeal filed as a complaint in federal District Court 

4. FEDERAL CMS GUIDANCE  on NY Integrated Appeals and Grievances Demonstration

CMS Webpage on Integrated Financial Alignment Initiatives for Dual Eligibles 

CMS Webpage for New York's Financial Alignment Initiative

 NY Integrated Appeals and Grievances Demonstration

On January 1, 2020, CMS and NYSDOH transitioned remaining FIDA enrollees to MAP plans and aligned D-SNPs. This transition also included extending the FIDA integrated appeals and grievances process to MAP and aligned D-SNP plans. Under the revamped NY Integrated Appeals and Grievances Demonstration, CMS and NYSDOH are testing the integrated appeals and grievances process begun under FIDA with a larger volume of full benefit dual eligible individuals. As of January 2020, approximately 18,000 individuals are enrolled in a MAP and aligned D-SNP plan.

5. REPORTS on the Integrated Appeal System:

• May 2022 - CMS First Report on  Financial Alignment Initiative for Medicare-Medicaid Enrollees New York Integrated Appeals and Grievances Demonstration - First Brief Report (PDF)   Related content:  Financial Alignment Initiative for Medicare-Medicaid Enrollees

• New York Integrated Appeals and Grievances Demonstration: Second Brief Report, April 2023 (RTI International,  prepared for CMS) (reporting that 84% of the 2^nd hearings concerned personal care and CDPAP in the first and second years of the demonstration, with the remaining 16%  split between home health, dental, DME, and pre-utilization determinations, and other services)  

6. ARCHIVE:  March 2021 Glitch - Healthfirst Failed to Auto-Forward 789 Appeals for Integrated Hearings  

The Healthfirst MAP plan failed to "auto-forward"  appeals for 789 members to the  Integrated Administrative Hearings Office (IAHO), which is administered by NYS OTDA,  under the process described below.   As a result, hearings to appeal  the "Appeal Decision Notice"  by the plan were never scheduled (this is the equivalent of the Final Adverse Determination for MLTC plans).   About 75% of these appeals involve the plan's denial of an increase in home care hours (personal care or CDPAP).  The rest involve denial of one-time requests like medical supplies or equipment, or other issues.

To remedy this mistake, the State Dept. of Health has ordered this plan to  give a "temporary approval" of  the requested increase in hours now until the end of the current authorization or the next assessment, whichever is sooner.  See letter sent by Healthfirst MAP to members.   If at the next assessment the plan determines that a reduction is justified, it may reduce services.  Advocates have asked DOH to confirm  that the plan may only reduce services at the reassessment for reasons outlined in DOH MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services, and  must provide advance notice of the proposed reduction with Aid Continuing rights.   

Also, the plan must reimburse members  who paid out of pocket for the requested increase in services after the adverse "Level 1" decision and prior to March 24, 2021.  

The plan has sent this notice to members affected by this mistake.  The notice explains the above actions, how to request reimbursement, and how to get help from the ICAN Ombudsman program. ​​​​​​​