MLTC Model Notice FAQ – Hearings for Members – Aid Continuing

July 1, 2015

By: Justin C. Tan

July 1st marks the date for compliance by managed care plans with mandated notice requirements for adverse decisions affecting their enrollees. A model notice has been introduced in order to make such notifications simpler and more effective for an enrollee, while simultaneously protecting an enrollee’s due process rights and reducing the administrative burden normally associated with these programs. The notice requirements now require notifying an enrollee that he/she is able to simultaneously file both an Internal Appeal and/or a Fair Hearing request, so long as the requests are made within their respective deadlines. Significantly, “Fair Hearings” go through a regulatory administrative hearings process and may result in mandatory compliance with coverage criteria.

Internal Appeals and Fair Hearing deadlines commence at the same time. The only discrepancy arises in the calculation of the duration of the submission deadline, in that the deadline to request a Fair Hearing is sixty (60) calendar days from the date of the notice, as opposed to the deadline for filing an Internal Appeal, which is sixty (60) working days. As such, a plan must add the following language on the Model Initial Adverse Determination (IAD) notice: “You have 60 working days from the date of this notice to ask for an Internal Appeal.”

Other clarifications affecting access to “Fair Hearings” include:

  • Elimination of Internal Appeal Exhaustion Requirement
  • Internal Appeal and Fair Hearing deadlines start to run at the same time
  • Deadline to request a Fair Hearing is 60 calendar days from the date of the notice
  • Members may file and pursue Internal Appeals and Fair Hearings simultaneously
  • Aid Continuing will apply if a Fair Hearing is requested within 10 days from the date of notice, or by the date the action takes effect

The new model notices must be used for MCO adverse actions on or after July 1, 2015. More information on this topic can be accessed at: