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New Permanent Nursing Home Residents in NYS Required to Enroll in Medicaid Managed Care Plans or MLTC Plans - Effective since October 2015 Statewide

Views: 8149
Posted: 08 Jul, 2014
by Valerie Bogart (New York Legal Assistance Group)
Updated: 07 Dec, 2016
by Valerie Bogart (New York Legal Assistance Group)

Since February 1, 2015, there has been a   new requirement for nursing home residents in New York City who became "permanent" residents after that date to enroll in Managed Long Term care (MLTC) and "mainstream" Medicaid Managed Care plans, which will now pay for and manage the nursing home care. CMS approved this expansion of MLTC and mainstream Medicaid managed care by letter of Dec. 31, 2014.   "Permanent" status does not begin until after  Institutional Medicaid eligibility has been approved, following the 5-year lookback.  Thus enrolling in a managed care or MLTC plan is not required for initial admission to a nursing home.  

The requirement started in NYC in February 2015, and the rest of the state was phased in by October  2015.

Since Jan. 22, 2015 and continuing through September 2015, NYS DOH has conducted a series of  webinars on this transition and has issued a series of policy papers and FAQs:  All are posted on the MRT 1458 website - scroll to the bottom to:

NYS Dept. of Health and NYC HRA Policies and Procedures 

NYS Dept. of Health Policies --Transition of Nursing Home Populations and Benefits to Medicaid Managed Care

Miscellaneous

State DOH Administrative Directive 15ADM-01 - Transition of Long Term Nursing Home Benefit into Medicaid Managed Care (April 1, 2015)  to local county Medicaid programs to explain the new procedures for Medicaid for nursing home care:   PDF         Attachment 1 

NEW YORK CITY PROCEDURES and FORMS - 

WHAT IS CHANGING FOR NURSiNG HOME RESIDENTS IN NYS?

Adults age 21+ becoming permanent nursing home residents in NYC after February 1, 2015 (estimated)  will be required to enroll in managed care plans starting in Feb. 2015 in NYC, in  Long Island and Westchester in April 2015. Upstate mandatory enrollment will begin in July 2015 on a rolling basis. The State's presentations above reviewed timelines, network requirements, reimbursement policies and other key areas of concern.

The type of managed care plan in which the individual must enroll depends on whether or not they receive Medicare.  

Current nursing home residents are "grandfathered in" - do not have to enroll in managed care plans.  Anyone already in a nursing home before Feb. 1, 2015 (and before Oct. 2015  outside of the NYC metro area) will not have to enroll in a managed care plan, and will continue to have Medicaid pay for their nursing home care on a "fee for service" basis.  The State says that no one already in a nursing home should have to change nursing homes because the nursing home is not in the plan's network.

If they are required to enroll in an MLTC plan or, if they are not on Medicare, in a "mainstream" managed care plan, they will enroll in a plan that affiliates and pays for their current nursing home.

This requirement will apply only people who, after Feb. 1, 2015, are approved for permanent nursing home placement and institutional Medicaid (after the 60-month lookback review is completed). It will not require enrollment into an MLTC or mainstream plan upon admission to a nursing home.. it will not be required until later, after they apply for and are accepted for institutional Medicaid.

Those who are already enrolled in an MLTC or mainstream Medicaid managed care plan in the community, who come to need long-term nursing home placement after Feb. 1, 2015 (if in NYC, or April 1, 2015 in Long Island and Westchester) or in other areas when they become mandatory, will no longer be disenrolled from the plan when they need nursing home care. They will need to choose a nursing home within the plan's network (or may sometimes change plans) and the plan will still manage their care in the nursing home.  

  • MLTC members who only need short-term rehabilitation care, however, may go to any rehab facility of their choice, and are not restricted to facilities in their MLTC plan's network.  The MLTC plan must pay the Medicare coinsurance for the skilled nursing facility (rehab) stay.  SEE DOH Q&A Aug. 16, 2012  - Question 42 on page 7.  However, once the Medicare-covered stay is over, they must switch to an MLTC plan that includes their preferred nursing home in its network.  If the Medicare stay is less than 29 days, they may get additional days up to a total of 29 days, including Medicare-covered days, under the community Medicaid short-term rehabilitation benefit.  For that care no 5-year lookback application is needed.

  • Mainstream members who need 29 days or less of nursing home coverage are entitled to Medicaid short-term rehab benefits, which covers up to 29 consecutive days under community Medicaid, without needing to do the 5-year lookback Medicaid application.

People who were NOT enrolled in an MLTC plan or mainstream plan who come to need nursing home care after Feb.  1st, 2015 (in NYC - rest of state timeline is here) may enter any nursing home of their choice.   They do not have to join an MLTC or managed care plan until after they are admitted to the home, apply for and are accepted for institutional Medicaid (which includes the lookback period that screens for transfers of assets)

Phase-In Schedule - The original date was March 1, 2014, which was delayed several times.  New schedule here.     Concerns raised by NYLAG and other consumer advocates by letter of March 14, 2014,  were part of the reason for the delay, with CMS requesting further protections in the state implementation plan.  Now, with the  ICAN Ombudsprogram   and the Conflict-Free Evaluation and Enrollment Center up and running, CMS has approved this expansion of managed care.  See more about this in this article in September 2014 news. People who first become permanent Nursing Home  residents after the dates below, meaning their eligibility has been determined after a 60-month Lookback application, must enroll in either a Medicaid Managed Care or d Managed Long Term care plan, which one depends on whether they have Medicare.

Consumer Advocacy

Advocacy organizations including Medicaid Matters NY, the Coalition to Protect the Rights of New York's Dual Eligibles (CPRNYDE) and other organizations have participated in workgroups, voicing consumer concerns about many aspects of this expansion of managed care.

Attached files
file MICSA-NHED Submission Protocol Transition of NH into MMC-MLTC 10-26-15.pdf (794 kb)
file Issues in Carve-in Nursing Home Benefit CPRNYDE 10-22-15.pdf (353 kb)
file 2015-10-28 NH Transition to Managed Care Forms and PDF Training Material.pdf (1.17 mb)

Also read
document Transfer of Asset Rules in Medicaid -- The Deficit Reduction Act of 2005
document Nursing Home Medicaid Coverage - Basic Financial Eligibility Rules about Income, Resources, and Spousal Protections
document Managed Long Term Care
document Maintaining Community Medicaid (Non-Chronic Care) Budgeting During Temporary Nursing Home Stays
document Medicaid Short-Term Rehabilitation Benefit
document Medicaid Managed Care
document Tools for Choosing a Medicaid Managed Long Term Care Plan
document Appeals & Grievances in Managed Long Term Care - Consumer Rights
document Consumer Advocacy on the FIDA Demonstration - Fully Integrated Dual Advantage - Managed Care Covering Medicare and Medicaid Services Starting 2015

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

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