Here are some important tips regarding your rights as a recipient of services from a Medicaid Managed Care Organization (MCO). You can also download the flyer here.
1. You have a right to disagree with your MCO and with the MCO care coordinator, and the right to ask for more or different services. Remember, services must be ordered by a health care provider.
2. You have a right to a written notice at least 10 days before any decision to terminate, suspend or reduce any existing service. If your service provider tells you that your MCO is reducing your services and you have not gotten a notice, you need to tell the service provider and your MCO that they cannot reduce your services without giving you prior, written notice and the opportunity to appeal.
3. You have appeal rights whenever your MCO is proposing to terminate, suspend or reduce an existing service , refusing to re-authorize an existing service, denying a request for a new service or not acting in a timely way.
4. There are different types of appeals for when you disagree with your MCO. It is important to understand the differences.
a. An internal appeal allows you to challenge a decision regarding your care within the MCO system, meaning people the MCO employs or contracts with will be making a decision on your appeal.
i. You have 90 days from the date your notice was mailed to ask for an internal appeal.
ii. If you request your internal appeal within 10 days of the date the notice was mailed (keep your envelope; sometimes the notice has a date that is earlier than when the MCO actually mailed it!!!) you can get services continued. You have to indicate that you want your services to continue. if you lose your appeal you may be held financially responsible for those services.
iii. You have a right to a representative of your own choosing when you do an internal appeal. You can but you do not have to use the MCO patient advocate.
iv. You should read your member handbook for more information on other types of appeals, such as expedited appeals and peer to peer (e.g., doctor to doctor) appeals.
b. A state fair hearing allows your case to be reviewed by a decision maker who is outside of the MCO. You have a right to request a state fair hearing without filing an internal appeal with an MCO. You can file both. In fact, CLASI generally recommends that you file for both, and that you do so within 10 days of the mailing of your notice if you want your benefits to continue during your appeal.
i. You have 90 days from the date the Notice of Action is mailed to ask for a state fair hearing. You must put your request in writing and file it with the state fair hearing office.
ii. If you file your written request for a state fair hearing with the state fair hearing office within 10 days of the date of mailing of the notice or before the action date, you can get services continued while you wait for the outcome of your appeal. When you elect for the services to continue during the appeal, you may be financially responsible for the services if you lose your appeal.
iii. You can bring an advocate of your choice to the state fair hearing. Before your hearing, you have a right to review your file and any documents the MCO intends to use at your hearing. You also have a right to the rules the MCO used in making its decision, including laws and regulations.
c. An MCO grievance is NOT an appeal and does not challenge the merits of any decision that the MCO has made. It is a way to complain about the manner in which you were treated by a provider or the MCO or its employees.
5. If your MCO is preparing or revising a Plan of Care and you are not happy with it, you can refuse to accept the Proposed Plan of Care, and indicate that you disagree with it and why.
a. If you refuse to sign it, or sign indicating that you do not agree, you are entitled to a written notice with the opportunity for an internal MCO appeal and a state fair hearing.
b. Even if you don’t get a notice, you have a right to file a request for a state fair hearing.
Please call Community Legal Aid Society toll free at (800) 292-7980 or seek other legal counsel if your services are changed without getting a notice, or if you receive a notice that the MCO wants to terminate, suspend or reduce an existing service or has denied a service ordered by your treatment source, and you disagree with that decision.
General tips for dealing with a health insurance company, including an MCO:
1. Document everything. Keep all of your letters with the envelopes stapled to them.
2. Keep a log of every conversation, including the name of the person you spoke to, what you spoke about, and the date and time.
3. Do not allow someone to make a decision verbally. Insist on a written notice.
4. Pay close attention to deadlines.
5. Get a receipt for any documents you give them. Keep copies! Send letters certified mail with a return receipt. This is especially important if you have a deadline or are requesting that your services continue during your appeal – if the paperwork is lost you need to be able to prove that you filed it on time!
6. Have the full and complete cooperation of your doctor or service provider. Make sure they agree with your requests for services. If they are required to submit documents to the insurer, make sure to follow up politely and make sure that this was done.
