Since Managed Long Term Care (MLTC) plan enrollment has been mandatory since 2013 for most adult "dual eligibles" (people with Medicaid and Medicare) who need Medicaid home care, some MLTC plans have either closed or reduced their service area, no longer covering certain counties or New York City.
What happens to a plan's members when a plan closes altogether, or in a particular county or city? Since September 22, 2017, under NYS DOH MLTC Policy 17.02, members of a closing plan have important Transition Rights. They are automatically assigned to a new plan, which is required to provide the same services that the closing plan provided for 120 days or until there is a reassessment and the enrollee has agreed to a new plan of care.
OCTOBER 2021 WARNING - STATE CUTTING BACK ON CONSUMER RIGHTS AFTER THE 120-DAY TRANSITION PERIOD ENDS -- See below.People with questions about these possible changes and about Transition Rights can call the ICAN Ombudsprogram at 1-844-614-8800. If their care manager or another plan employee, or an employee of the home care agency that provides their MLTC home care services, tells them that they should change plans or that the plan is closing, they should report this to ICAN or directly to the State Dept. of Health MLTC Complaint line at 1-866-712-7197 or e-mail mltctac@health.ny.gov . See Fact Sheet for Consumers on Plan Closings. This article explains: A. Recent and Expected Plan Closings - Status - ICS, Guildnet, United HealthCare upstate B. Details about the MLTC Policy 17.-02 . C. Consumer advocate concerns about the policy
D. Past Plan Closings - 2015 thru mid-2018 E. Strategy for Consumers Faced with Plan Closings or Reductions in Service Area ==================================================================================== A. Recent MLTC Plan Closings or Withdrawal from Counties -
B. Sept. 2017 NYS DOH Policy 17.02 when MLTC Plans Close or Reduce Service AreaOn September 22, 2017, the New York State Department of Health issued a directive called, "MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration." This policy directive clarifies an important protection for enrollees in a plan that is closing. Members will receive a notice from New York Medicaid Choice, the States enrollment broker for managed care, that they should select a new plan within sixty (60) days of the date of the notice. The notice will state that if they do not select a plan within sixty (60) days, they will be auto–assigned to a new MLTC plan. There should be no interruption of services.
C. Consumer Advocacy Concerns about Transition Policy 17.02The "new plan" must only continue services for the longer of: (i) 120 days after enrollment; or (ii) until the new plan has conducted an assessment and the enrollee has agreed to the new plan of care. The new plan is required to conduct an assessment within 30 days of the transfer enrollment effective date, unless a longer time frame has been expressly authorized by the Department in its sole discretion." Consumer advocates have expressed concern to the State Department of Health about various aspects of this policy.
WARNING - Protections now in effect are changing...see below.. Until the changes take effect, although MLTC Policy 17.02 is silent on member rights after the 120-day transition period, the law is well established that Medicaid home care services may only be reduced if the plan states in a notice and can prove that the member's condition has improved or other circumstances changed, causing her to need less care. A federal court found that this protection is required by the Due Process clause of the Fourteenth Amendment of the U.S. Constitution. Mayer v. Wing, 922 F. Supp. 902, 911(S.D.N.Y. 1996). It is incorporated in state regulation. 18 NYCRR 505.14(b)(5)(v)(c)(2)(ii), and has been expressly applied to MLTC plans. See MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services (which also allows reductions in very limited situations if a "mistake" was made by the prior plan or agency)
These changes are in amendments to State regulations effective Nov. 8, 2021, posted here. As of late October 2021, it is not clear exactly when these changes go into effect, which will allow an MLTC plan to reduce hours after the transition period it it determines that the previous plan or Medicaid agency "authorized more services than are medically necessary,” without proving any change. The Plan only has to give notice that "indicates a clinical rationale that shows review of the client’s specific clinical data and medical condition." 18 NYCRR Sec. 505.14(b (4)(viii)(c)(3)(vii), 505.28(i)(4)(iii)(h) as amended eff. 11/8/21 (posted here - at pp. 60 and 137 of the PDF). The plan will still be required to give written notice BEFORE reducing services, with the right to request a Plan appeal and AID CONTINUING, which is the right to continue services at the higher amount authorized by the closing plan, until the appeal is held and decided. After the plan appeal, the member has the right to 10-day advance notice, to request a Fair Hearing with Aid Continuing within the 10-day notice period. See more about MLTC Appeals and Hearings here.
D. Past MLTC Plan Closings in NYS
Who is affected? Wellcare MLTC plan had members in the following counties prior to closure June 1st as follows. Anyone still in the plan as of May 2020, and possibly some who transitioned in the few months before, has transition rights.
ICS members were transferred to VNS Choice unless they selected another plan. The had a special 1-year transition period that ended April 1, 2020. See this Fact Sheet - KNOW YOUR RIGHTS: February 2020 Update for Former ICS Members Fact Sheet. More about ICS closing 3/31/2019 -- see more here and in this news article. Click here for the latest updates on the Guildnet closing. Guildnet enrollees received this official notice the week of 10/15/2018, and must choose a new plan by 12/19/2018 if they do not want to be auto-assigned to a new plan. Under MLTC Policy 17.02 they can call NY Medicaid Choice which will do a "warm transfer" to their selected plan, without the need for a Conflict Free assessment (CFEEC). These letters followed confirmation on Sept. 20, 2018 by the NYS Dept. of Health that Guildnet is terminating all of its health insurance products in New York State effective 1/1/2019, including the following plans shown with enrollment as of August 2018 (TOTAL - 8,211 members - all in NYC): Guildnet Medicaid Advantage Plus - 478 members
Guildnet Gold Plus (FIDA) 417 members
Guildnet MLTC - 7,316 members
Transition Rights - Continuity of Care -- Under MLTC Policy 17.02, the new plan must continue Guildnet's service plan with the same providers and same amount of home care and other services for 120 days after the enrollment, "or until the new plan has conducted an assessment and the enrollee has agreed to the new plan of care."
These transitions are subject to the new MLTC Lock-In policy that is effective for changes in plans 12/1/18 or later… New guidance was just issued on this. See Licensed Home Care Services Agencies (LHSCA) Contract Limitation Guidance – 08.17.2018
See more updates about Guildnet closing in this news article
News media reported in July 2018 that talks with the State are underway regarding the possible closing of ICS, an MLTC plan founded in 2000 that is in operation in four boroughs of New York City. See WNYC Radio, New Yorkers with Physical Disabilities Rally to Save Health Care Plan (July 9, 2018) and Crain's NY Business, Disability Advocates Fear Closure of Specialized Plan (July 5, 2018). The Crain's article cites a memo dated June 22, 2018 circulated within the plan's Member Council, of which NYLAG obtained a copy, which states, "The NYS Department of Health will probably announce in the early fall that ICS will cease operations as an MLTC plan by the end of the year." The ICS memo explains that members would receive 90 days notice to choose another plan, or they would be assigned to VNS Choice MLTC plan. The memo states further, "Members will be guaranteed the same level of care (continuity of care) for at least 120 days or until a new assessment is done." The ICS memo states, "It is in each ICS member's best interest to stay at ICS until notification comes from DOH because the extended continuity of care will only be offered to people at ICS at the time of notification." The reason ICS recommends that members stay at ICS until notification comes from DOH is because of language in the State guidance, "MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration." That guidance, described more below, can be read to require a new plan to continue the ICS plan of care for 120 days only for members who transfer to the new plan after ICS' request for plan closure and notices to members about the closure have been approved by the Department of Health. Until that happens, ICS members who transfer plans are at risk of having their services cut if they change plans. While consumer advocates may disagree about whether the continuity of care rights should apply even before official DOH approval is given, the safest strategy is for ICS members to remain in ICS until official notice is provided by the State. The Crain's article quotes one active ICS member who said, "ICS' members are more likely to require 12 hours or more of home care a day than members of other plans, which warrants higher reimbursement from the state. A push to include funding for higher rates in the budget failed." The article quotes Victor Calise, Commissioner for the Mayor's Office for People with Disabilities as stating, "ICS is the only MLTC plan that is capable of providing the specialized care needed to maximize the number of people with disabilities who are living in the community." IMPACT: 6,182 Members in NYC as of August 2018 - see this chart
Warning that as of now, MLTC Policy 17.02 does not specifically apply to FIDA. However, if participants in terminating FIDA plans choose to switch to another FIDA plan, they will be given a 90-day transition period per the 3-way FIDA Model Three–Way Contract (§ 2.6.6.1). It is less clear what transition rights members of a closing FIDA plan have if they switch to an MLTC plan. Stay tuned for more on that. This is especially critical for Suffolk County residents, where the plan that is closing - Agewell FIDA - was the ONLY FIDA plan, so they do not have the option of switching to another FIDA plan. They may switch to the sole Medicaid Advantage Plus (MAP) plan in Suffok County (VNS Choice FIDA) or to the sole PACE plan in Suffolk (Centerlight PACE). Members of closing FIDA plans in Nassau County and NYC who do not select a new plan will be auto-assigned to another FIDA plan. Remember Medicare Part D! Additionally, If a member of a closing FIDA plan decides to switch to an MLTC plan instead of to another FIDA plan or another "fully capitated" plan like PACE or Medicaid Advantage Plus, they must remember to select and enroll in a Medicare Part D prescription drug plan for January 1, 2019. Before, the FIDA plan covered their drugs. Now, they need to enroll in a stand-alone plan. For more info on Medicare Part D see a training manual and other info here and see NYS plans in 2019.
Before the merger, in Sept. 2017, AlphaCare had 4,459 enrollees, mostly in NYC with a few in Westchester., and Senior Whole Health had 9,141 members in NYC. As of June 2018, only 3 members remain in Alphacare, and Senior Whole Health has 13,726 members, all in NYC except for 219 in Westchester. (Statistics from DOH Managed Care Enrollment Reports.)
SOURCE: NYS DOH Monthly Managed Care Enrollment Statistics. New York Newsday publicized the closing on September 1, 2017, Northwell to end long-term care plan that covers 6,000 elderly, The North Shore MLTC closing is the first one that applied the new Transition Policy issued by the State Dept. of Health, described below. Centers Plan was poised to increase its current enrollment of 18,600 to become the largest partial capitation MLTC plan in the state. Comparison of the 4 largest MLTC plans in the state at the time was as follows: FOUR LARGEST MLTC PLANS IN NYS - ENROLLMENT Sept. 2017
UPDATE 1: In October 2017 - NYS DOH reportedly is permitting Guildnet to notify its remaining 930 Guildnet members in the three affected counties that they have 60 days to select a new plan, or they will be auto-assigned to another plan, pursuant to the new DOH MLTC Policy 17.02 described below. See consumer strategies below to advise clients who receive these letters. UPDATE 2: - FORMER GUILDNET MEMBERS MAY ASK FOR HOURS TO BE RESTORED - About 3,000 former members of Guildnet MLTC plan in Long Island and Westchester who transitioned to another plan after March 20, 2017, have received this Sept. 29, 2017 letter from the State telling them they must call New York Medicaid Choice before Prior history - Guildnet closing - In April 2017, Guildnet sent notices to its over 4,200 members in the 3 affected counties (Westchester, Suffolk, and Nassau) that they had to select a new plan by May 18, 2017 "to assure a smooth transition." Members panicked when other plans either could not schedule assessments before that date, or offered to accept the enrollee but with hours reduced compared to the number Guildnet authorized. On May 13, 2017, NYS Dept. of Health sent over 4000 letters to members of Guildnet MLTC plan in the 3 counties that clarified that Guildnet had requested to pull out of those 3 counties, but that members were not required to find a new plan by June 1st, and that Guildnet was required to continue providing them with MLTC services "until a smooth transfer can be completed to your new plan." The letter did not say what happens if the enrollee could not find a plan willing to provide the same hours as Guildnet authorized. See letter posted here. In June 2017, a lawsuit called "Turano" was brought by the New York Legal Assistance Group, through its Special Litigation Unit,, representing Guildnet members harmed by the lack of a "transition policy" that guarantees a transition of members from Guildnet in the 3 counties to another MLTC plan with the same number of hours that Guildnet authorized. For more information contact NYLAG Special Litigation Unit at 212-613-5032. Between November 2016 and September 2017, Guildnet enrollment in the affected 3 counties declined as follows (source: NYS DOH Monthly Managed Care Enrollment Statistics): GUILDNET ENROLLMENT in Long Island & Westchester Nov. 16 - Sept. 17 - June 2018
In October 2017 - NYS DOH reportedly is permitting Guildnet to notify its remaining 930 Guildnet members in the three affected counties that they have 60 days to select a new plan, or they will be auto-assigned to another plan, pursuant to the new DOH MLTC Policy 17.02 described below.
Enrollment in Elderplan in Suffolk county has decreased from 302 members in Nov. 2016 to 184 in Sept. 2017.
E. Consumer Strategies When Plans CloseConsumers who receive notices that their plan is closing - whether North Shore LIJ MLTC or Guiildnet now in late 2017, or other plans in the future -- should not enroll in any other plan that does not ensure in writing that they will approve the same services that the plan that is closing approved. They should either (1) wait to be automatically assigned to a plan by New York Medicaid Choice OR (2) find a plan that contracts with the same home care agency or CDPAP provider the consumer wants, and enroll in that plan after consumer receives the 60-day notice to select a plan). Consumers may not be able to get a new plan to assess them at home in time to select a plan before being "auto-assigned" to a new plan. Under the new Policy 17.02, they should be protected because ANY plan they are assigned to MUST continue the same hours that the closing plan authorized at least for a time. They need to be vigilant for any threat to reduce services by the new plan, and request a hearing if any cut in hours or services is threatened - whether by written notice or even an oral threat. WARNING -- Given that MLTC Policy 17.02 allows plans to reduce services if the consumer "agrees," consumers should be careful not to indicate agreement to a reduction. Send a letter that they do not agree to a reduction. Be sure to keep proof of faxing, emailing or mailing this statement. If the member transitions to a new plan - whether a plan they select or a plan they are auto-assigned to -- and the new plan indicates it will reduce services, request a fair hearing right away and contact ICAN or other legal services program. Request a hearing even if the new plan does not provide written notice of the reduction. ICAN provide assistance or representation in some cases. For questions, contact ICAN - (844) 614-8800
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