Medicaid Fair Hearings
What Happens Right After My Medicaid Approval
Generally, after you are approved for Medicaid, the Nassau or Suffolk County Department of Social Services or the New York City HRA, will refer you to select a managed long-term care (MLTC) provider. The MLTC will then send out a nurse to evaluate how many hours of services you qualify for.
The criteria that the MLTC uses is supposed to be objective. The problem is that the MLTCs are financially incentivized to provide the least amount of services possible. So, what happens, is the evaluating nurse often makes a determination that you need less hours than you may actually be entitled to.
As a starting point, I recommend to my clients that if given a choice of MLTCs, they call two or three and ask each to do an evaluation. Often, you will get different numbers of hours approved for each MLTC. Then I suggest they select the one that offers the most hours. However, sometimes, the maximum number of hours offered is still insufficient. When that happens, you have the opportunity to appeal.
What About an Adverse Decision Reducing My Hours?
Another scenario you may be facing is that you’ve been receiving Medicaid assistance for some time, and the MTLC came in and re-evaluated you and approved less hours than you were receiving previously. That can be extremely frustrating.What is an Internal Appeal?
The first level appeal is an Internal Appeal. The instructions for your Internal Appeal will be found on your Initial Adverse Determination Letter or Final Adverse Determination Letter. Depending on the MLTC, this can be done either online, by phone, by letter, or by fax. You should take this opportunity to make your best case for why the hours are insufficient. Although I do not recommend that clients make this argument on their own, many do make it on their own in order to save money on legal fees. Sometimes they get what they are looking for, but often the way they formulate their argument is insufficient, and they get denied, or they only get a small increase in hours. When that happens, the next step is to request two types of reviews. One is called an Expedited External Appeal and one is called a Fair Hearing.What is an Expedited External Appeal?
An Expedited External Appeal is a process where you submit your argument for more hours to an independent firm certified by Medicaid to review your submission and determine if the MLTC offered a sufficient number of hours, or if more hours are warranted. The decision is usually made within 72 hours, which is why they call it Expedited. This is done by submission only.What is a Fair Hearing?
A Fair Hearing a hearing held before an independent administrative judge who is a member of the New York State Office of Temporary and Disability Assistance (OTDA), Office of Administrative Hearings. These meetings are held either in-person, during normal times, or by telephone at times like during the COVID-19 pandemic. Both sides will submit documents in support of their positions. Both sides also have the opportunity to present oral argument.
It often takes 20-60 days until the date for the Fair Hearing. While you are waiting, you then have to begin preparing for the Fair Hearing by gathering the medical records to support your argument, letters of medical necessity from the attending physician, and looking up relevant case law and statutory law. When your written submission is ready, you send a copy to the OTDA prior to the date of the hearing.
Should I Request an Expedited External Appeal and a Fair Hearing?
Because the Fair Hearing may be far out, the best strategy to employ is to request a Fair Hearing as soon as possible, but then to also prepare the submission for an Expedited External Appeal. The same materials you use for the Fair Hearing can be used for the Expedited External Appeal. The main difference is that you will not have oral argument at the Expedited External Appeal.
If your Expedited External Appeal is decided in your favor, you then only have to withdraw you request for the Fair Hearing. On the other hand, if your Expedited External Appeal is denied, you will still have your chance to make your case at the Fair Hearing.
Should I Hire a Fair Hearing Attorney?
Since the outcome of these decisions can have a significant impact on the number of hours you receive, I always recommend that you or your family does not go it alone.
Conclusion
If you have received an adverse Medicaid hours determination from your MLTC, call us—we can help you through your Nassau County, Suffolk County, and New York City Expedited External Appeal and Medicaid Fair Hearing process to give you the greatest chance to receive the maximum Medicaid assistance hours you are entitled to. 