Appeals, Fair Hearings & ICAN

If we deny a request for services, reduce the amount of services you receive, or stop a service you are currently receiving, you have rights and options available to you.

This page explains the review and appeal options available for long-term care services and supports.

When Can I Request a Review?

You may have the right to take action if we:

• Deny a request for a service
• Approve fewer services than requested
• Reduce the services you are currently receiving
• Suspend or stop services
• Deny payment for a service

When this happens, we will send you a written notice explaining the decision and the options available to you.

What Is a Plan Appeal?

A Plan Appeal is a request for us to review a decision we made about your services.

You, your authorized representative, or your provider may request an appeal on your behalf.

During the appeal process, we will review the information related to your case and determine whether the original decision should be changed.

Need a Faster Decision?

You may request an expedited appeal if waiting for a standard decision could seriously jeopardize your life, health, or ability to attain, maintain, or regain maximum function.

If your situation qualifies, we will review your appeal as quickly as your condition requires.

What Is a Fair Hearing?

A Fair Hearing is a review conducted by the New York State Office of Temporary and Disability Assistance (OTDA).

You may have the right to request a Fair Hearing if you disagree with a decision affecting your Medicaid-covered services.

An Administrative Law Judge will review the facts of your case and issue a decision.

Information about how to request a Fair Hearing will be included in your notice. You can request a Fair Hearing online at otda.ny.gov/oah/FHReq.asp. Information about how to request one will also be included in your notice.

What Is Aid Continuing?

In certain situations, you may be able to continue receiving services while your appeal or Fair Hearing is pending.

This is often referred to as Aid Continuing.

To qualify, your appeal or hearing request must generally be submitted within the timeframe specified in your notice.

Your notice will explain whether Aid Continuing may be available and how to request it.

What Is an External Appeal?

Some decisions involving medical necessity may qualify for an External Appeal.

An External Appeal allows an independent reviewer outside of the health plan to review the decision.

If an External Appeal is available, you can request one through the New York State Department of Financial Services at dfs.ny.gov. Information about your rights and how to request one will be included in your notice.

Free Help Through ICAN

The Independent Consumer Advocacy Network (ICAN) is New York State’s independent ombudsman program for people receiving long-term care services.

ICAN can help you:

• Understand your rights
• Understand notices and decisions
• File appeals
• Request Fair Hearings
• Navigate the long-term care system

ICAN services are free and confidential.

Appointing a Representative

You may appoint a family member, friend, attorney, provider, or another individual to act on your behalf during the appeals process.

A completed representative form may be required.

Need Help Understanding Your Options?

Member Services and your Care Management Team can help explain your rights, notices, and available review options.