NYAPRS Note: Medicaid Matters is a statewide, consumer-oriented organization that advocates on behalf of the Medicaid program and the persons it serves. NYAPRS is a MMNY Steering Committee member as well as a member of the Managed Care workgroup. Below, find the 2014 policy and budget priorities for the coalition as well as the MC workgroup. To find ways to assist MMNY or join them in their advocacy, visit them here.
1)Medicaid Matters 2014 Policy and Budget Agenda
The interests of people served by the New York’s Medicaid program are the focus of the advocacy of
Medicaid Matters New York (MMNY). For all New Yorkers, no matter their circumstances, the hallmark
of maintaining good health is accessibility.
Access to Coverage
• Implement a Basic Health Program
• Ensure cultural competency in all aspects of New York State of Health, including language
accessibility and general access for immigrants
• Integrate eligibility for non-MAGI and people using other public programs; train navigators and
provide adequate consumer information
• Improve the New York State of Health website and call center functions to promote general
accessibility and ease of use; increase marketing to low-income populations, and provide
information about Medicaid and all public programs available
Access to Services
• Enact and enhance strong consumer protections in Medicaid Managed Care and all models of
care management (see MMNY Managed Care Workgroup agenda)
• Address health disparities based on race, ethnicity, disability (physical, psychiatric, and
developmental), sexual orientation and identity, and any other circumstance; implement
recommendations previously submitted through MRT Health Disparities Workgroup and other
efforts
• Invest in community-based services and safety-net providers, particularly as needs will change
due to increase in people with insurance and shifts to new managed care models
• Invest in social determinants of health
• Ensure network adequacy in all care delivery models
Access to Consumer Assistance
• Provide funding for robust advocacy and assistance services for people with disabilities and
chronic needs in Medicaid managed care
• Continue funding for overall consumer assistance in New York State of Health, including after
enrollment
• Provide specific funding for people with disabilities to access consumer assistance with eligibility
and enrollment, including after enrollment
• Mandate all consumer notices from the state and managed care plans be clear and standardized
Access to Information and Participation
• Guarantee transparency in the allocation of all Medicaid funding, particularly through new
funding mechanisms being considered with new waiver amendment application
• Include consumer advocates in the work and negotiations on waiver amendments, state plan
amendments, managed care contracts, and any other changes to the Medicaid program
• Increase funding for health information technology to support new and growing models of care
2)MMNY Managed Care Workgroup 2014-2015 Managed Care Budget Agenda
• Eliminate exhaustion requirement for Medicaid recipients enrolled in Managed Long Term Care
The state requires dually-eligible Medicaid recipients enrolled in MTLC to “exhaust” all
internal appeals within their managed care plan before requesting a fair hearing when services are
denied, reduced or terminated. Federal regulations give states the option to require “exhaustion” of
internal appeals, but the Department of Health has imposed this requirement. This requirement
threatens to bar access to appeals for some of the most vulnerable Medicaid populations – seniors
and people with disabilities.
• Repeal the policy that Medicaid recipients enrolled in MLTC are not entitled to Aid-Continuing
when the reduction coincides with the end of the plan’s authorization period
The right to notice and a hearing before reduction or termination of benefits is a fundamental
due process right. In the MLTC program, however, managed care plans may authorize Medicaid long
term care services with no advance notice and no right for the consumer to receive services while a
hearing is pending, if the plan’s service reduction coincides with the end of the plan’s “authorization
period” for the services.
• Mandate all Medicaid managed care plans to use standardized notices created by DOH with
stakeholder input
Medicaid managed care plans are required to use notices that have been reviewed and
approved by DOH. The notices, however, are not uniform across type of care or plan. Some plans
include a list of appeal options that includes an external appeal with the New York State Department
of Financial Services, even though this is not available for all denials. Standardized notices would
reduce consumer confusion. The notices should be created with the assistance of literacy experts
and allow for stakeholder input. Denial and reduction notices should include information on how to
access legal representation and provide the information for complaint lines.
• Require Medicaid managed care plans to provide an evidence packet to an appellant when a
hearing is requested
When an enrollee requests a fair hearing, the Medicaid managed care plan creates an
evidence packet in preparation for that hearing. The plans should be required to automatically
forward a copy of that evidence packet to the appellant.
• Require Medicaid managed care plans to provide access to utilization data
Medicaid managed care plans are required to maintain a health information system that
collects, analyzes, integrates, and reports data, including but not limited to utilization data. It is
important that beneficiaries and their advocates have access to this data. The state should require
the plans to release utilization records to Medicaid members and, with a member’s permission, to
their advocates.
• Expand the Medicaid Managed Care Ombudsman Program
As mandatory enrollment into Medicaid managed care expands to people who have
historically been exempt or excluded, there will be a significant need for individual, independent
assistance for people as they enroll, attempt to access services, and navigate the complexity of
managed care. The Medicaid Managed Care Ombudsman Program will be available across the state
to fund such assistance. The state should increase funding to the program to allow it to reach
capacity and be available as more people are enrolled in Medicaid managed care.
• Expand the Medicaid Managed Care Advisory Review Panel
As the only statutorily-required forum for stakeholder input regarding Medicaid managed care
issues, MMCARP membership should reflect a strong voice for Medicaid consumers, who are the
most vulnerable and most directly impacted by policy changes to the Medicaid program. As Medicaid
managed care is expanded to populations not previously required to enroll, such as people with
disabilities and long-term, complex needs, MMNY urges DOH to expand membership from the
consumer advocate community.
http://www.medicaidmattersny.org/index.html