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Tools for Choosing a Medicaid Managed Long Term Care Plan

Views: 48369
Posted: 10 Jul, 2012
by Valerie Bogart (New York Legal Assistance Group)
Updated: 01 Aug, 2016
by Peter Travitsky (New York Legal Assistance Group)

As described in this article, most adults in NYC, Westchester, Nassau and Suffolk counties who have Medicaid and Medicare, who are receiving Medicaid home attendant or housekeeping ("personal care") services through their local Medicaid "CASA" office, or long-term CHHA or adult day care services, must select and enroll in a managed long term care plan, or a PACE or Medicaid Advantage Plus plan.  If they don't select one within 60 days of receiving an enrollment letter from New York Medicaid Choice, they will be assigned to a "partially capitated" managed long term care (MLTC) plan. (See more information on the enrollment process)

The information they will receive --  Links to the information consumers are receiving from New York Medicaid Choice is in this article, including the following: 

  1. Official Guide to Managed Long Term Care, written and published by NY Medicaid Choice (Maximus) - note - consumer advocates had the opportunity to review a very early draft of this guide months ago, but never had the chance to review or see the guide again until today)

  2. List of Plans - Partial-Cap MLTC, PACE, and Medicaid Advantage Plus -  (NY Medicaid Choice lists, which include contact info. and links to web sites) 

If the consumer does not select a plan, they are randonly assigned to a plan.  Even if New York Medicaid Choice helps them pick a plan, we understand that the sole criterion NY Medicaid Choice will use in plan selection is the plan network of providers -- this company will have access to an internal database showing all of the networks of providers in each plan, so that it can recommend a plan that contracts with the providers of the client's choice. 

Here is other information that may be helpful in selecting a plan.  

NYS Dep't of Health MLTC Consumer Guides and Reports

All MLTC plans are required to report certain quality data to the State.  The State posts reports each year at this link. including some results of customer satisfaction surveys conducted by the Dep't of Health.  These data for have been summarized on the DOH website, and may help consumers comparing different plans:

Please note that consumer advocate have criticized the State's reports for lacking important information that is necessary for consumers to make an informed choice about plans.  See  New York’s 2012 Managed Long Term Care Report: An Incomplete Picture (April 2013)  -- The Coalition to Protect the Rights of New York’s Dually Eligible issued this "Incomplete Picture" Report as a critique of the NYS Dept. of Health's 2012 Managed Long Term Care Report, issued in December 2012.  The  State's Report does not provide the full spectrum of information that beneficiaries need to make informed health care choices -- For example, The 2012 Report presents the most favorable findings of consumer surveys, but fails to mention less positive but important findings from IPRO’s report, including the fact that higher need respondents in poorer health were significantly more likely to raise concerns about services than those in good health.  The Report fails to include any meaningful utilization data, showing the amount of and type of services provided by MLTC plans or the medical-loss ratios of the various plans.  The Report fails to comply with the Public Health Law that requires the report to  present information  in a way that allows beneficiaries to make meaningful comparison between plans.  Inadequate quality data is reported as well.  

ASK PLAN TO COME TO HOME,  ASSESS NEEDS & DESCRIBE PROPOSED CARE PLAN BEFORE ENROLLING.

The State's Q & A issued Aug. 21, 2012 states:

Q39. How do new Medicaid applicants enroll into MLTC? Can they be assessed by multiple plans prior to enrolling or must they enroll in order to get assessed for services?

A39. Consumers new to service must be assessed prior to enrollment. Consumers may contact multiple plans and request assessment, however, services will not be provided until they are enrolled in a plan.

Q44. In mandatory enrollment zip codes, if a consumer contacts a plan to see options during the 60 day period, if a plan conducts a visit, is the consumer entitled to a written plan of care before the enrollment?

A44. The plan is responsible for issuing a written plan of care.

Information about plans

Services Plan has Historically Provided

Through Freedom of Information requests, data has been released that the Evelyn Frank Legal Resources Program, now part of New York Legal Assistance Group, has analyzed.   Click here for data from 2010 and 2011 showing charts that compare the amount of home care hours plans provided to their members in 2010 and 2011, the medical loss ratio of various MLTC plans (percentage of premium spent on care vs.administrative overhead), and other data.  

ADA - Americans With DIsabilities Act Compliance by MLTC Plans

An analysis completed by the Center for Independence of the Disabled NY (CIDNY) found MLTC Plans  out of compliance with   ADA requirements.  See  Letter to Mark Kissinger, Dep. Commissioner NYS DOH, dated  Oct. 5, 2012, from Susan Dooha, Exec. Director, CIDNY, posted at  http://tinyurl.com/CIDNY-MLTC-ADA, referencing Chart Comparing MLTC ADA Plan Compliance, posted at http://tinyurl.com/CIDNY-MLTC-ADA-chart-xls.  

Continuity of Care Requirements - Requires Plan to Contract with Former Providers for Short Period

One important factor in choosing a plan is whether you can keep your aide that worked with you when CASA/DSS or a CHHA authorized your care before you enrolled in the MLTC plan?   Statewide, the new MLTC plan is required to contract with all  home attendant/personal care agencies, certified home health agencies, Lombardi programs, and other care providers that previously had contracts with the local Medicaid program, at least through March 1, 2014.  See   Final Continuity of Care Policy for Managed Long Term Care.  This policy is intended for them to be able to keep the same aide they had in the CASA program.   If they learn that the assigned MLTC plan does not contract with their current home attendant  or home care vendor, they should ask the MLTC plan to do so so that they can keep their aide.  Cite the above policy.  If the MLTC plan refuses to allow the client to keep her aide, call the State Dept. of Health at 1-866-712-7197 (MLTC Complaint Line)

PLAN PROVIDER NETWORKS

Despite requests from advocates, the State has not made publicly available any online listing of provider networks.  While NY Medicaid Choice has access to some internal database, this is not being made public.  The only public information is that posted on the plan's own websites or that the plan will mail you upon request.  To help you identify networks, we have compiled information to the extent available as of July 2012.     

Is Provider Network Adequate?

The MLTC Model Contract requires the MLTC plan to "...have a minimum of two (2 ) providers that are accepting new Enrollees in each county in its service area for each covered service in the benefit package unless the county has an insufficient number of providers licensed, certified or available in that county as determined by the Department.

4. Providers of covered services to which an Enrollee must travel must be geographically accessible for the enrolled population. Travel times must not exceed:

a. Thirty (30) minutes from the Enrollee’s residence in metropolitan areas;

b. Thirty (30) miles from the Enrollee’s residence in non-metropolitan areas.

5. If the Contractor is unable to provide necessary services through its contracted network for a particular Enrollee, the Contractor agrees to adequately and timely furnish these services outside of the Contractors’ network for as long as the Contractor is unable to provide them within the network

DOH Model MLTC Contract, Article VII Part D (p. 46)

Look at whether your other providers are in the plan's network.   For example --

Nursing Homes in Network and QUALITY of care in Nursing homes

WHAT NURSING HOMES ARE IN MY PLAN'S NETWORK?  -NYLAG is beginning to compile charts to compare networks of plans from the directory information listed below.   The first type of provider network compiled is for NURSING HOMES covered by each plan.  

Q42. As discussed on the MLTC weekly call, can you please confirm that the following assertions are true, and if not, please clarify the policy on the following: (1) MLTC plans must pay the member’s Medicare coinsurance for skilled in-patient rehabilitation services provided in an SNF, regardless of whether the facility is in the MLTC plan’s nursing home network.

A42. Yes, Managed Long Term Care plans must pay the member’s Medicare coinsurance for nursing facilities.

NOTE - However, after the Medicare coverage ends, MLTC plan may decline to pay for nursing home care unless member transfers to an in-network nursing home.  The MLTC plan must cover the cost of care pending a reasonable period to transfer.  Q&A dated Aug. 16, 2012 Q&A No. 49.

Dentists 

In addition to a plan’s network of dental providers,  MLTC recipients as well as mainstream managed care members have the right to access dental services at Academic Dental Center clinics licensed under article 28 of the NY Public Health Law. N.Y. Pub. Health Law § 4403-f(7)(b)(vii)(D) (MLTC statute expressly incorporating Medicaid managed care requirements at N.Y. Soc. Serv. § 364-j(4)(a)(iii)(D)).

There are five dental centers in New York State that meet these criteria. They are: 

  1. Columbia University College of Dental Medicine;
  2. New York University College of Dentistry;
  3. Stony Brook University School of Dental Medicine;
  4. University of Buffalo School of Dental Medicine (Daniel Squire);
  5. University of Rochester Eastman Dental Center.

Under the Model MLTC contract, dental services at these clinics may be accessed without prior approval and without regard to network participation. Plan must reimburse at reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates.  See Article VII(H)(1) at page 48 of contract.   See also MAP Model Contract, at § 22.12(a); PACE Model Contract, at Art. V(L)(c)(sic).  

See N.Y. Dep’t of Health, Question and Answer Sheet: Transition of Dental and Orthodontia Coverage from Fee for Service to Medicaid Managed Care

Optometry

Like dental care, optometry services provided by Article 28 clinics affiliated with the College of Optometry of the State
University of New York may be accessed directly by Enrollees without the Contractor’s prior approval and without regard to network participation.    Model MLTC contract Article VII(G)(1) at page 48.    NYLAG will post list of these clinics soon.  Main clinic is

University Eye Center - also offers Homebound visits
SUNY College of Optometry
33 West 42nd St
New York, NY 10036     Phone: (888) 277-5666 or (212) 938-4001   Pre-register using our Online Appointment Form 

MLTC Plan Provider Networks - Where to Find Info (based on info provided by plans and State DOH January 2013)

PLAN How info available Phone Notes
AgeWell New York Directory online 866-586-8044
Aetna Better Health

Member Handbook

Directory online

1-855-456-9126 

AlphaCare

Directory Online

(855) 363-6110

Member handbook

ArchCare Community Life Directory online 866-263-9083 Click here for  Member Handbook in English & Spanish, with Westchester version

Centerlight Healthcare Select MLTC

Directory online - searchable database 877-226-8500
Centers Plan for Healthy Living Directory online 855-270-1600
ElderServe Directory Online 800-370-3600
Extended MLTC NO WEBSITE AS OF 11/22/13
Fidelis Care at Home Searchable database online (select "Fidelis Care at Home," note if provider accepting patients 800-688-7 422 Must search for particular provider types, no full single directory available.
Guildnet Directory online 800-932-4703
HealthPlus MLTC (Amerigroup) Directory online 800-950-7679
HHH Choices Health Plan Directory online 866-663-6877
HIP MLTC

Directory online

888-447-4838 Caution not to get networks for other HIP Medicaid managed care plans
HomeFirst/ ElderPlan

Directory online: NYC & Westchester County, Nassau County, Monroe County

718-759-4510
Independence Care System Directory online 877-427-2525
Integra MLTC no directory online 1-855-800-4683 Member handbook in English, Russian and Spanish
MetroPlus MLTC Provider Directory

855-355-MLTC(6582)                  (TTY: 1-800-881-2812).

North Shore-LIJ MLTC (855) 421-3066

Plan approved by State 10/21/2013

Provider directory

Member handbook 
Senior Health Partners Call for directory.  Selfhelp obtained in August 2012 and uploaded here. 800-633-9717
Senior Whole Health MLTC Directory online (direct link) or through this webpage

Members  1-877-353-0185

Enrollment 1-877-353-0188

United Health Personal Assist

View Member Handbook (English)

Directory online

1-877-512-9354
VillageCare Max Directory online.    800-469-6292
VNSNY Choice MLTC Directory online 888-867-6555 Revised May 2012
WellCare Advocate MLTC Directory online 866-661-1232 Updated once/year - call for more current info

MEDICAID ADVANTAGE PLUS

Plan Name How Network Info Available  Phone Number  Member Handbook and Additional Notes
Elderplan, Inc.   866-386-9437 Elderplan materials available here.

Dual-Eligible (HMO SNP) Medicaid Advantage Plus MLTC

Directory
888-447-9161    TDD 888-447-9161
Fidelis Searchable database online (select "Medicaid Adv. Plus," note if provider accepting patients 877-533-2404 Must search for particular provider types, no full single directory available.
Guildnet Gold, Inc. Network info online here - scroll down to Provider & Pharmacy Directory and click on borough of choice 800-932-4703 or 800-815-0000 Member handbook available here.
HealthFirst Complete Care Doctors and hospitals are http://www.healthfirstny.org/our-network-doctors.htmlonline, but not any other services. Presumably LTC services network is same as Senior Health Partners, affiliate MLTC plan. 888-260-1010
HealthPlus, an Amerigroup Company Doctors and other medical providers in MAP plan online here.  Long term care does not appear to be online 866-805-4589 Member handbook available here.
Senior Whole Health M/M Plus Directory online for some plans, but says to call for additional info about provider availability for Medicaid Advantage Plus 877-353-0185 Member handbook available here.
VNSNY CHOICE Total Directory online for Total plan as of 2/2013.   See info on networks here. 866-597-6674 Member handbook available for download here.
WellCare Advocate Complete Directory online, but shows network for various Medicaid & Medicare plans, and cautions that some benefits vary by plan. 866-661-1232 Evidence of Coverage  available  here.

PACE

Plan Name How Network  Info Available  Phone Number  Member Handbook and Additional Notes
ArchCare Senior Life

Directory online

866-263-9083
Centerlight Healthcare PACE Directory online for NYC, Nassau, Suffok & Westchester 877-226-8500 Member rights listed here.


This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.

NYLAG

Attached files
file MLTC-MAP-PACE Plan List by Company - April 2014 - NYLAG_140512132608.pdf (207 kb)
file MA Chart NYS February 2013 with MAP - MA - MLTC - Outside NYS.pdf (33 kb)
file SHP Provider Directory 7.12.xls (201 kb)
file MLTC Nursing Homes Final.xls (134 kb)
file 2010Q4 MLTC data highlights NH use.pdf (6 kb)
file 2010Q4 MLTC data highlights expense.pdf (8 kb)
file 2010 MLTC -PACE data HHA-PCA hours.pdf (35 kb)
file LA-MLTC-Notice Sample with Envelope.pdf (178 kb)
file 2015-05-28 MAP DR-05 Provider ID Numbers and Plan Codes.pdf (164 kb)
file Medicare Advantage-MA-MA Plus enrollment NYC 2-2013.pdf (11 kb)
file STATEWIDE LIST OF Managed Long Term Care 6 and 4-2015.pdf (526 kb)
file Nursing Home MLTC Network NYS FOIL April 2013 from LTCCC.xlsx (50 kb)

Also read
document Medicaid Personal Care or Home Attendant Services
document CASA Contact List - NYC
document Medicaid Consumer Directed Personal Assistance Program (CDPAP) in New York State
document Managed Long Term Care
document Grievance and Appeal Contacts for Managed Long Term Care Plans
document Appeals & Grievances in Managed Long Term Care - Consumer Rights
document Statistics on Medicare and Medicaid Managed Care -- Enrollment Numbers and other Data -- New York State
document New Permanent Nursing Home Residents in NYS Required to Enroll in Medicaid Managed Care Plans or MLTC Plans - Effective since October 2015 Statewide
document KNOW YOUR RIGHTS: Managed Long Term Care and FIDA - Fact Sheets, Live and Recorded Webinars

External links
http://nymedicaidchoice.com

Also listed in
folder Medicaid -> Home Care
folder Medicaid -> Medicaid Managed Care

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