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.  

TERMINOLOGY:

• A request for a NEW service that was not previously authorized  is "Prior Authorization."
• Aan INCREASE in a service they already have  is "concurrent review",, such as more hours of personal care or consumer-directed personal assistance (CDPAP) 

APRIL 1, 2026 CHANGE - Federal regulations take effect in NYS that reduce how much time the managed care or MLTC plan has to decide some requests for prior authorization or concurrent review from 14 calendar days to 7 calendar days.  The new times are indicated below. 

 Sources of law: 

• Federal regulations at 42 CFR 438.210 (amended in 2016, effective in NYS May 1, 2018;  except for one provision reducing a deadline for plan to make a determination from 14 to 7 days is effective in NYS April 1, 2026.

• NYS Public Health Law Sec. 4903 (in some cases  has stricter deadlines than federal regulations)

•  State's Model  contracts with the plans

  • MLTC contracts at this link under "Model Contracts"

    • MLTC Model Contract - For 1.1.22 - 12.31.26 - see Appendix K - #3. "Service Authorizations) (pp. 173-176 of the PDF)

  • "Mainstream" Managed Care contracts with plans posted here 

    • Contracts amended, effective April 1, 2021 -see Appendix F (starts p. 332 of the PDF)

TIME LIMITS FOR PLAN TO PROCESS A REQUEST FOR NEW or INCREASED SERVICES

Contract and 42 CFR 438.210 provide that Plan must decide and notify Enrollee of decision by phone and in writing as fast as the Enrollee’s condition requires but no more than the following timeline.

In NYS, these requests have  particular names under the NYS Public Health Law, and in the state's contracts with the managed care and MLTC plans:

a.   "Prior authorization" -  a request by the Enrollee or provider on Enrollee’s behalf for a new service (whether for a new authorization period or within an existing authorization period) or a request to change a service as determined in the plan of care for a new authorization period.

• Expedited - 72 hours from request for service, subject to 14-day extension described below, if:

  • If the member or provider request that a request  be expedited, plan must decide request in 72 hours  if the plan determines or the provider indicates that a delay "would seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function."   If the plan denied the Enrollee’s request for an expedited review, the plan will handle as standard review.

• Standard – within 3 business days of receipt of necessary information, but no more than  7  calendar days of receipt of request for services, subject to extension described below.  NOTE:  Time limit reduced from 14 to 7 calendar days effective April 1, 2026 per 42 CFR 438.210(d)(1).  

b. "Concurrent review "- a request by an Enrollee or provider on Enrollee’s behalf for more services than the amount  currently authorized in the plan of care (such as increased hours of personal care or CDPAP) or for Medicaid covered home health care services following an inpatient admission.

• Expedited – within 72 hours of receipt of request, on,  subject to up to 14-day extension described below.

  • same standard  as for expedited prior approval requests above

• Standard – within  7 calendar days of receipt of  request,   subject to up to 14-day extension described below.   NOTE:  Time limit reduced from 14 to 7 calendar days effective April 1, 2026 per 42 CFR 438.210(d)(1).  

• In a request for Medicaid covered home health care services following an inpatient admission,   one (1) business day after receipt of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in any event, no more than three (3) business days after receipt of the request for services.  NYS Pub. Health Law Sec. 4903, subd. 3

When Plans May Extend Deadline by 14 Days  

The plan may extend the 72 hour time period for expedited reviews and the 7 day time limit for standard reviews by up to 14 calendar days if the enrollee requests an extension, or if the MCO, justifies (to the State agency upon request) a need for additional information and how the extension is in the enrollee's interest   42 CFR 438.210(d) 

• The plan must give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision; and Issue and carry out its determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires.  42 CFR 438.404(c).  

Model Plan Notices - Managed Care & MLTC

Model notices of approvals or adverse determinations are posted DOH Service Authorizations  & Appeals webpage - for both regular mainstream managed care plans and MLTC plans

•  Initial Adverse Determination
  • Denial Notice - (Web) - (PDF) - 11.4.2021 revised 2024
  • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021 (has Aid Continuing rights) - revised 11/2024
• Approval Notice - (Web) - (PDF) - 11.20.2017
• 14-day Extension Notice - (Web) - (PDF) - 11.4.2021, revised 11/2024

If consumer files a Plan Appeal of an Initial Adverse Determination  notice,  then Plan must issue a --

•  Final Adverse Determination (this is after a Plan Appeal - see article on appeals)
  • Denial Notice - (Web) - (PDF) - 11.4.2021 revised 11/2024
  • Notice to Reduce, Suspend or Stop Services - (Web) - (PDF) - 11.4.2021 revised 11/2024 (has Aid Continuing rights)

If Plan Does Not Issue a Determination By the Deadline,  Member May File a Plan Appeal Anyway

If the plan does not issue a decision on a request for services within the timeframes specified in  42 CFR 438.210 described above, this constitutes a denial and is thus an adverse action.  The consumer may requeset an internal Plan Appeal in that case,  just as if a written decision can be appealed.  42 CF.R. 438.404(c)(5).  See article on Appeal & Grievances in MLTC. The benefit for the consumer is that the plan's delay in issuing the determination does not prevent the consumer from proceeding through the Plan Appeal and then to a Fair Hearing.   If the plan delays in issuing a decision on the Plan Appea beyond the applicable  deadline, then the consumer may request a Fair Hearing. The requirement to "exhaust" the plan appeal is "waived" if the plan misses that deadline.  See article on Appeal & Grievances in MLTC. The same rules apply for mainstream managed care as for MLTC. 

 New "Independent Assessor" procedures  for requests for Personal Care or CDPAP

NY Independent Assessor (NYIAP)  -- New procedures for how plans assess and determine eligibility for Personal Care and CDPAP. 

• What is the Independent Assessor?  Click here for article.  - this includes   NYLAG advocacy on NYIA, PowerPoints with more info, WHERE TO COMPLAIN about delays, and other problems.

• An MLTC member who requests prior approval of a new service or a concurrent review of an existing service does NOT go through NYIAP.  The consumer makes the request to the MLTC plan, which must render a decision under the timelines above. 

• A mainstream managed care member who requests prior approval of personal care or CDPAP services for the first time from the managed care plan, however, will be referred to request an assessment from NYIAP.  Only after NYIAP completes that assessment and issues an Outcome Notice is the member referred back to the plan to proceed with the prior approval process and issuing one of the notices above.  Advocates believe that the delays caused by requiring the NYIAP assessment inevitably results in plans violating the 7-day deadline above.

MORE ABOUT REQUESTING INCREASES OF HOURS OF HOME CARE

See Tips on Requesting Services from a Medicaid Managed Care or MLTC plan, including Increases in Hours of Home Care  (RUSSIAN TRANSLATION  NEW August 2021)

See these parts from our article on Medicaid personal care services, which also applies to CDPAP.  The same rules apply whether the services are obtained through an MLTC or other managed care plan, or from the local DSS.

• How Much Personal Care?  How are Hours Determined?

• Standards for 24-Hour Care - Definition  of Live-in and Split Shift

• Standards for Assessing Need and Determining Amount of Care

Fact Sheet: Tips on Requesting Services from a Medicaid Managed Care or MLTC plan, including Increases in Hours of Home Care  (RUSSIAN TRANSLATION  NEW August 2021)

 WHERE TO GO FOR HELP 

See this article.

This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.