The Federal Government has approved, effective August 9, 1999, the implementation of mandatory managed care under the Partnership Plan, a demonstration waiver program approved under section 1115 of the Social Security Act. The Partnership Plan encompasses most of the non-elderly, non-institutionalized Medicaid population. The Office of Administrative Hearings will be providing the fair hearings for this program.
In general, local social services districts (LDSS) are responsible for actual eligibility determinations, education, and enrollment functions, as well as for contracting with Managed Care Organizations (MCOs). In NYC, enrollment functions will be handled by a Contracted Enrollment Broker (currently Maximus), which is under contract with the State Department of Health. MCOs will make clinical determinations, which will be subject to hearings. For clinical determinations, the MCOs will be a party to the hearing. Any fair hearing requests received on issues related to managed care must be handled in accordance with negotiated procedures; unfortunately, due to on-going discussions with the Department of Health, such procedures have yet to finalized.
Medicaid recipients requesting services from an MCO may request a fair hearing because his/her claim for services is denied or is not acted upon in a reasonably prompt manner. In addition, such recipient may request a fair hearing because he/she believes that the agency has taken an action (termination, suspension, or reduction) on his/her services erroneously.
Clients applying or enrolled in managed care will have fair hearing rights
regarding enrollment issues, including denials of exclusions and exemptions, denials of their requests for disenrollment from a managed care plan and LDSS or SDOH approvals of requests of MCOs to disenroll a recipient. For a more comprehensive listing of potential hearable issues, limitations and aid-continuing rights, please refer to pages 23-7 through 23-10 of the above-mentioned Operational Protocol.
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