Relates to Medicaid reviews and appeals

BILL NUMBER:S6586

Title of bill

An act to amend the social services law and the public health law, in relation to medicaid reviews and appeals

Purpose or general idea of bill

To clarify that Medicaid enrollees who have been denied services by a Medicaid managed care plan may file for a fair hearing under the Social Services Law as well as internal and external appeal under managed care laws, and are entitled to the continuation of services as usual while appeals and fair hearings proceed.

Summary of specific provisions

The bill amends Social Services Law 22 and Public Health Law § 4403-F to assure that Medicaid enrollees do not have to exhaust internal and external appeals of managed care plan adverse determinations in order to proceed with Medicaid fair hearings. The bill amends Social Services Law § 265-a to clarify that health care services continue until the appeal(s) is resolved.

Justification

Medicaid recipients are increasingly moved into managed care plans subject to the managed care internal and external appeal processes. This is being used to assert that the recipients may not file for a Social Services Law fair hearing until those managed care appeals are exhausted. Unfortunately, this has the effect of depriving recipients of their longstanding right to have services continue while a fair hearing appeal is pending. This can have the effect of depriving people of health care services to which they are legally entitle.

This bill will assure that the remedies of managed care benefits appeals are cumulative to Medicaid fair hearing rights and that health care services once determined to be medically necessary are not threatened by bureaucratic delays in either appeal process.

Prior legislative history

New bill

Fiscal implications

None

Effective date

Immediately and apply to any appeal pending at the time.