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 is being phased out to end December 31, 2025. 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 page 8 of this explanation from the Integrated Care Resource Center. 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.

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.

2.  For MEDICAID -  a Medicaid Advantage Plus  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
• Transitions for FIDA beneficiaries in 2019
• Important long-term care definitions
• Coverage options for dually eligible New Yorkers FAQ
• Medicaid Advantage Plus (MAP) appeals

LISTS OF 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 the fourth  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.   

 Integrated Appeal System for MAP plans - Started 2020 and being phased out - Use if service was requested before Dec. 31, 2025

Steps in Integrated Appeal Process

MAP members who want to appeal an adverse decision by the MAP plan issued BEFORE Dec. 31, 2025 denying or reducing Medicaid personal care or CDPAP services (or any other  plan services) must use an integrated appeal and hearing procedure that is slightly different than the regular OTDA Fair Hearings used for MLTC.   In both MAP and MLTC, “exhaustion” of the plan appeal is required first before a fair hearing.  See article on MLTC appeals and exhaustion.

• The  Integrated Appeal process essentially continues 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.  

• How is the MAP-FIDE Appeal System Different than MLTC Appeals and Hearings?

1. Initial adverse notice  (request for new or increased service or notice of reduction) -

   Notices have different names 

• MLTC Notice called "Initial Adverse Determination" or IAD - Model denial IAD and  Model reduction IAD

• MAP notice called "Coverage Determination Notice" - download Integrated Beneficiary Notices (ZIP) 

LEVEL 1 APPEAL - in both MAP and MLTC, member must request an internal appeal  of the initial adverse notice within the plan, and 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 theh PDF) that governs MAP hearings. 

2. Plan Notice Denying Internal Plan Appeal - 

Notices have Different Names:

• MLTC Notice Called "Final Adverse Determination" or FAD -  Model Denial FAD  and  Model Reduction FAD  -

• MAP "Appeal Decision Notice" --  (from Integrated Beneficiary Notices (ZIP))

2. LEVEL 2 APPEAL - Request for Hearing -  Two different hearing  systems for MLTC and MAP - 

   • MLTC - Member must request a Fair Hearing with NYS OTDA like any other Medicaid hearing.  If the action is a threatened reduction, member must request the hearing in time to get Aid Continuing - before the Effective Date of the reduction.  

   • MAP "FIDE" Hearings - are 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.

3. 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.

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

5.    OPTIONAL STEP WHILE FAIR HEARING PENDING - EXTERNAL APPEAL

   Both the MLTC FAD notice and the MAP-FIDE Plan Appeal Decision notice (in this zip file) explain that the member has the right to file an External Appeal with the NYS Dept. of Financial Services, which is NYS's insurance department.   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 "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.   

   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 appeals here.  The State DFS External Appeal website is here.  

MORE ABOUT MAP Integrated HEARING PROCEDURES 

• Obtaining the Evidence Packet for the Hearing -  

  • MAP plan SHOULD send it automatically to the member, without having to request it.  See the sample Appeal Decision Notice.  The MOU at pagd 3 specifically requires MAP plans to comply with other requirements in the managed care regulations - 42 C.F.R. Part 438, which requires plans to provide the case file during the plan appeal. 

  • MLTC - Plan SHOULD have provided the member with their file during the course of the initial plan appeal.  42 CFR 438.406(b)(5).  If plan did not, member has right to request it for the hearing.  

• Submitting Evidence for the Hearing - because of COVID-19, all hearings are being held by phone.  See 20 GIS TA/DC 097 – NYS OTDA Office of Admin. Hearings (OAH) Transmittal 20-05 - Allowing or Requiring Fair Hearing Appearances by Written, Telephonic, Video, or other Electronic Means.  

  • MAP - Submit evidence by FAX:  518-473-8783 Email:  otda.sm.MAP.Integrated.Appeals.Office@otda.ny.gov  

Mail: Integrated Appeals/IAHO-10A, P.O. Box 1930, Albany, NY 12201

• MLTC - FAX 518-473-6735  or 

Email:  otda.sm.fhdocuments.submissions@otda.ny.gov

• Phone Contact to OTDA re Scheduling, Adjournments, Etc.

MAP:  IAHO           1 (844) 523-8777

MLTC: OTDA OAH 1 (800) 342-3334

• Deadline for IAHO Decision - As in all Medicaid hearings, a final hearing decision must be made in 90 days from the hearing request (or plan's automatic referral for the fair hearng).  MOU Appendix 3 Sec. 3.6.1

3.   WARNING re Varshavsky case and Home Hearings:   Members of regular MLTC plans have some special hearing rights 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 is taking the position that Varshavsky does not apply to MAP-FIDE  hearings.  

There are two important benefits of Varshavsky that as of now apply only to people in MLTC and not MAP plans.  See Varshavsky fact sheet for more about these benefits. 

• First, 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,  even before COVID-19 there were long delays in scheduling home  hearings, which must be held and decided within 90 days under the class injunction.  Therefore, 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 hearing.

See Varshavsky Fact Sheet with more info and tips.

 FEDERAL CMS GUIDANCE  on NY Integrated Appeals and Grievances Demonstration:and MODEL FORMS 

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.

Federal regulations - The MOU refers to 42 C.F.R. 422.633, which was amended on Jan. 19, 2021, as part of  new requirements applicable to certain Integrated  Dual Eligible Special Needs Plans.  See 86 FR 6103

• Memorandum of Understanding (MOU) (PDF)  - between NYS and CMS
• Integrated Beneficiary Notices (ZIP) (including):
  • • Integrated Coverage Determination Notice
    • Expedited Appeal Request Denial Notice
    • Appeal Extension Notice
    • Appeal Denial Notice
• CY 2020 Evidence of Coverage (Chapter 9 (DOCX))
• MAP Handbook Addendum (DOCX)
• CY 2020 Annual Notice of Changes (DOCX)

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)  

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.