The Legal Aid Society of New York, a former member of the ICAN network, wrote this guide to explain your rights as a member of a Managed Long Term Care plan, and answer some common questions about grievances and appeals.

You have Rights as a Member of a Managed Long Term Care Plan.

If you have questions about these rights, contact an ICAN Advocate.

• You have the Right to receive medically necessary care.
• You have the Right to timely access to care and services.
• You have the Right to privacy about your medical record and when you get treatment.
• You have the Right to get information on available treatment options and alternatives presented in a manner and language you understand.
• You have the Right to get information in a language you understand; you can get oral translation services free of charge.
• You have the Right to get information necessary to give informed consent before the start of treatment.
• You have the Right to be treated with respect and dignity.
• You have the Right to get a copy of your medical records and ask that the records be amended or corrected.
• You have the Right to take part in decisions about your health care, including the right to refuse treatment.
• You have the Right to be free from any form of restraint or seclusion used as a means of coercion, discipline, convenience or retaliation.
• You have the Right to get care without regard to sex, race, health status, color, age, national origin, sexual orientation, marital status or religion.
• You have the Right to be told where, when and how to get the services you need from your managed long term care plan, including how you can get covered benefits from out-of-network providers if they are not available in the plan network.
• You have the Right to complain to the New York State Department of Health or your Local Department of Social Services; and, the Right to use the New York State Fair Hearing System and/or a New York State External Appeal, where appropriate.
• You have the Right to appoint someone to speak for you about your care and treatment.

Copied from the Managed Long Term Care Model Contract, Appendix L.  You have more rights as a managed care consumer under New York State law.

What is a Grievance?

ICAN Advocates can help you file a Grievance with your MLTC plan.

A grievance is any communication by you to your MLTC plan of dissatisfaction about the care and treatment you receive. For example, if someone was rude to you or you do not like the quality of care or services you have received from your MLTC plan, you can file a grievance.

You may file a grievance orally or in writing with your MLTC plan. The person at your MLTC plan who receives your grievance will record it, and appropriate plan staff will oversee the review of the grievance. Your MLTC plan will send you a letter telling you that they received your grievance and a description of their review process. Your MLTC plan will review your grievance and give you a written answer. This answer will describe what your MLTC plan found when they reviewed your grievance and the decision they made about your grievance.

What is an Appeal?

ICAN can help you file an Internal Appeal with your MLTC plan.

If your MLTC plan decides to reduce, suspend, or stop your services, your plan must send you a notice labeled Initial Adverse Determination at least ten days before they plan to make any changes. Your notice should include information about how to appeal and how to keep your services the same during the appeal. Your notice should include information about deadlines to file your appeals.

If you did not receive a notice and your services were stopped or changed, you need to request an Internal Appeal with “Aid to Continue” right away. ICAN can help you with this.

You may also have the right to an Internal Appeal if your MLTC plan denies or limits services requested by you or your provider, denies a request for a referral, decides that a requested service is not a covered benefit, denies payment for services, doesn’t provide timely services, or doesn’t make grievance or appeal determinations within the required timeframes.

ICAN can help you understand any notice your MLTC plan mails to you. ICAN can help you appeal an Action by requesting an internal appeal. ICAN can explain your options and help you solve problems. ICAN services are free, confidential, and independent.

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