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Managed Long Term Care
State Complaint Number for MLTC Problems - 1-866-712-7197
Managed Long Term Care (MLTC) plans are insurance plans that are paid a monthly premium ("capitation") by the New York Medicaid program to approve and provide Medicaid home care and other long-term care services (listed below) to people who need long-term care because of a long-lasting health condition or disability. The MLTC plans take over the job the local CASA or Medicaid offices used to do – they decide whether you need Medicaid home care and how many hours you may receive, and arrange for the care by a network of providers that the plan contracts with.. They also approve, manage and pay for the other long-term care services listed below.
In addition to this article, for latest updates on MLTC --see this NEWS ARTICLE on MLTC Implementation.
You can also view and listen to a recording of the entire webinar at this link:
The PowerPoint and Appendix used in the webinar are available at the following links:
90-Day Transition Period - On May 8, 2013, the State extended the time that MLTC plans must continue providing the same amount and type of home care services that new members previously received from a CASA, DSS, or CHHA from 60 days to 90 days. Read more about the Transition Period.
|Month||New Schedule||"MLTC Announcement" letter sent||60-day "Choice" letters sent||"Front door" closed - no new Personal Care applications at local Medicaid office|
|9/2012 - 12/2013||
NYC, Albany, Erie, Monroe, Nassau, Onondaga, Orange, Rockland, Suffolk, Westchester
|Jan 2014||Columbia, Putnam, Sullivan, Ulster||April 2014||early May 2014||May __ 2014|
|June 2014||Cayuga, Herkimer, Oneida, and Rensselaer||Week of May 23, 2014||week of June 2, 2014||May 30th|
|July 2014||Greene, Saratoga, Schenectady, and Washington||Week of June 30th||Week of July 14||July 7, 2014|
|August 2014||Dutchess, Montgomery, Broome, Fulton, Schoharie||Week of Aug. 29th||Week of Sept. 22nd||September 8, 2014|
|September 2014||Delaware, Warren||Sept. 15th||Oct. 1st||Sept. 22nd|
|October 2014||Niagara, Madison, Oswego||Week of Oct. 27, 2014||Oct. 20th|
|November 2014||Chenango, Cortland, Livingston, Ontario, Steuben, Tioga, Tompkins, Wayne||November 2014?|
|December 2014||Genesee, Orleans, Otsego, Wyoming||Week of December 29, 2014||Jan. 5, 2015|
|January 2015||Chautauqua, Chemung, Seneca, Schuyler, Yates, Allegany, Cattaraugus|
|February 2015||Clinton, Essex, Franklin, Hamilton, Jefferson, Lewis, St. Lawrence||February 2015|
|July 2015||Allegany, Clinton, Franklin, Jefferson, Lewis, and St. Lawrence.||July 3, 2015|
FINAL PHASE (No date set) - People in Assisted Living Program, Nursing Homes, TBI and Nursing Home Transition and Diversion Waiver Programs will all be required to enroll.
In NYC and Counties Where MLTC is Mandatory, WHO DOES NOT HAVE TO ENROLL IN MLTC? (Exemptions & Exclusions)
WHO MAY NOT ENROLL IN A MLTC? (Who is EXCLUDED from MLTC?)
Download New York Medicaid Choice MLTC Exclusion Form - must be signed by physician
Individuals in Certain Waiver Programs. These include: Nursing Home Transition & Diversion (NHTD) waiver, Traumatic Brain Injury (TBI) waiver, Office for People with Developmental Disabilities waiver, and individuals with complex mental health needs receiving services through ICF and HCBS waiver. (Note NHTW and TBI waivers will be merged into MLTC in January 2018).
Nursing Home residents WERE excluded from enrolling in MLTC plans or mainstream Medicaid managed care plans but MAY enroll as of Oct. 1, 2015. New permanent residents MUST enroll. SEE this article.
Medicaid Assisted Living Program residents;
Persons receiving hospice services (they may not enroll in an MLTC plan, but someone already in an MLTC plan who comes to need hospice services may enroll in hospice without having to disenroll from the MLTC plan. See NYS DOH MLTC Policy 13.18: MLTC Guidance on Hospice Coverage (June 25, 2013) Those who are in hospice and need supplemental home care may still apply to CASA/DSS for personal care services to supplement hospice;
Residents of Intermediate Care Facilities for the Developmentally Disabled (ICF/DD), Alcohol & Substance Abuse Long Term Care Residential Program, adult Foster Care Home, or psychiatric facilities.
People who receive or need ONLY "Housekeeping" services ("Personal Care Level I" services under 18 NYCRR 505.14). Under state law, these services are limited to 8 hours per week. If someone does not need assistance with Activities of Daily Living - personal care such as bathing, grooming, walking but only with household chores, they access these services through their Local Medicaid Program (in NYC apply to the Home Care Service Program with an M11q. See --
Children under age 18
NOTE - the recently obtained (2/2013) New York Medicaid Choice MLTC Exclusion Form excludes an individual certified by physician to have a developmental disability.
SOURCE: CMS Special Terms & Conditions, Amended Sept. 2012), at p. 14 -15
Download New York Medicaid Choice MLTC Exclusion Form - must be signed by physician
WHO MAY ENROLL IN MLTC BUT IS NOT REQUIRED TO? (WHO is EXEMPT FROM MLTC?)
Dual eligible individuals age 18- 21 who require home care or other long-term care services, and require a “nursing home level of care,” meaning they could be admitted to a nursing home based on their medical and functional condition;
Adults over age 21 who have Medicaid but not Medicare (If they require a “nursing home level of care”) -- If they are not yet enrolled in a a mainstream Medicaid managed care plan they may opt to enroll in an MLTC plan if they would be functionally eligible for nursing home care. If they enroll in an MLTC, they would receive other Medicaid services that are not covered by the MLTC plan on a fee-for-service basis, not through managed care (such as hospital care, primary medical care, prescriptions, etc.). However, if they are already enrolled in a mainstream Medicaid managed care plan, they must access personal care, consumer-directed personal assistance, or private duty nursing from the plan. They may only switch to MLTC if they need adult day care, social environmental supports, or home delivered meals - services not covered by Medicaid managed care plans. See MLTC Policy 14.01: Transfers from Medicaid Managed Care to Managed Long Term Care
Working Medicaid recipients under age 65 in the Medicaid Buy-In for Working People with Disabilities (MBI-WPD) program (If they require a “nursing home level of care”).
SOURCE: CMS Special Terms & Conditions, Amended Jan. 2014, at p. 14
Under MLTC Policy 14.06: Implementation of the Conflict-Free Evaluation and Enrollment Center (CFEEC) anyone approved for Medicaid who is seeking Managed Long Term Care will need to first contact NEW YORK MEDICAID CHOICE and request a CFEEC assessment. If that assessment finds the person eligible for MLTC, then the person can enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350.
SEE NEW YORK MEDICAID CHOICE WEBSITE ON CFEEC - http://nymedicaidchoice.com/ask/conflict-free-evaluation-and-enrollment-center
This is being implemented pursuant to #28 of the Special Terms and Conditions, which is CMS's approval of the State's 1115 waiver to implement mandatory MLTC, DOH has established a conflict-free assessment system for all voluntary enrollments into MLTC, MAP and PACE effective October 1, 2014.
Before, private MLTC plans were responsible for determining eligibility for Medicaid-covered long-term services and supports (LTSS). This creates an intrinsic conflict of interest, because plans have a financial stake in avoiding high-cost members and attracting low-cost members. The CFEEC reduces this conflict by having New York Medicaid Choice (aka Maximus), rather than the MLTC plans, determine eligibility for MLTC.
The Conflict-Free Evaluation and Enrollment Center (CFEEC)s schedule and conduct initial assessment visits in the home or facility by a nurse (employed by or under contract with the CFEEC). Using the Uniform Assessment Tool, the CFEEC makes the determination of eligibility for Medicaid LTSS. If the CFEEC determines that the applicant is ineligible for Medicaid LTSS, it will send a written notice with appeal rights. If the CFEEC approves the applicant, then any MLTC, MAP, PACE or FIDA plan must accept the applicant's enrollment. If the plan disagrees with the CFEEC's determination of eligibility, it may pursue a dispute adjudication procedure via Maximus and DOH.
The CFEEC was rolled out in phases beginning in NYC in October 2014, and became statewide by May 2015.
- Will this delay enrollment into MLTC? Probably. MLTC plans may not accept an enrollment without confirmation from CFEEC that you are MLTC-eligible. That confirmation is valid for 60 days. The State FAQ (Q13) says the CFEEC assessment can be done while Medicaid application is pending, but since a Medicaid application can take more than 60 days - it can be risky. It is also unclear whether the consumer must only sign an MLTC plan enrollment form within 60 days of the CFEEC assessment, or must actually be enrolled in the plan by that date - the difference can be significant.
See new documents available from NYS DOH on the Conflict-Free Evaluation and Enrollment Center (CFEEC):
- 9.22.14 CFEEC presentation (PPT)
- 9.22.14 CFEEC recorded session (WMV, 16MB)
- 9.29.14 CFEEC Fact Sheet (PDF, 118KB)
- 9.29.14 CFEEC FAQ (PDF, 239KB)
MLTC plans must provide the services in the MLTC Benefit Package listed below. Once you are enrolled in a MLTC plan, you may no longer use your Medicaid card for any of these services, and you must use providers in the MLTC plan’s network for all of these services, including your dentist. The providers will be paid by the MLTC plan, rather than billing Medicaid directly.
MLTC Benefit Package (Partial Capitation) (Plan must cover these services, if deemed medically necessary. Member must use providers within the plan's provider network for these services).
- Home Care, including:
- Personal Care (formerly known in NYC as "Home attendant." If you need ONLY Housekeeping services (Level I services and not Level II under 18 NYCRR 505.14, NOT eligible for MLTC)
- Certified Home Health Agency Services (home health aide, visiting nurse, visiting physical or occupational therapist)
- Private Duty Nursing
- Consumer Directed Personal Assistance Program
- Adult Day Health Care (medical model and social adult day care)
- Personal Emergency Response System (PERS),
- Nutrition -- Home-delivered meals or congregate meals
- Home modifications
- Medical equipment such as wheelchairs, medical supplies such as incontinent pads, prostheses, orthotics, respiratory therapy
- Physical, speech, and occupational therapy outside the home
- Hearing Aids and Eyeglasses
- Four Medical Specialties:
- Audiology + hearing aides and batteries
- Optometry + eyeglasses
- Non-emergency medical transportation to doctor offices, clinics (ambulette)
- Nursing home care
NOTE WHICH SERVICES ARE NOT COVERED BY MLTC PARTIALLY CAPITATED PLANS -- but are covered by "fully capitated" Medicaid Advantage Plus or PACE plans
- Primary and acute medical care, including all doctors other than the Four Medical Specialties listed above, all hospital inpatient and outpatient care, outpatient clinics, emergency room care, mental health care
- Lab and radiology tests
- Prescription drugs
- Assisted living program
- Hospice services - MLTC plans do not provide hospice services but as of June 24, 2013, an MLTC member may enroll in a hospice and continue to receive MLTC services separately. Before s/he had to disenroll from the MLTC plan. PACE plans may not give hospice services. See NYS DOH MLTC Policy 13.18: MLTC Guidance on Hospice Coverage (June 25, 2013)
HOW DO PEOPLE IN MLTC Partial Capitation Plans Receive services not covered by the plans? These use -
- Original Medicare OR Medicare Advantage plan AND
- Regular Medicaid
WHAT SERVICES ARE "MEDICALLY NECESSARY?" The Federal Medicaid statute requires that all managed care plans make services available to the same extent they are available to recipients of fee-for- service Medicaid. 42 U.S.C. § 1396b(m)(1)(A)(i); 42 C.F.R. §§ 438.210(a)(2) and (a) (4)(i). The NYS DOH Model Contract for MLTC Plans also includes this clause: “Managed care organizations may not define covered services more restrictively than the Medicaid Program"
ENROLLMENT: What letters are sent in newly mandatory counties to people receiving Medicaid home care services through county, CHHA, etc -- 60 days to choose MLTC PLAN
You will receive a series of letters from New York Medicaid Choice (www.nymedicaidchoice.com), also known as MAXIMUS, the company hired by New York State to handle MLTC enrollment. See PowerPoint explaining Maximus/NY Medicaid Choice's role in MLTC enrollment (this is written by by Maximus)
"ANNOUNCEMENT " LETTER - Important Medicaid Notice-- This "announcement letter" is sent to people with 120 days left on their authorization period for Medicaid personal care, certified home health agency, private duty nursing, CDPAP, and medical model adult day care, or LOmbardi services, telling them "MLTC" is coming letter sent in English and Spanish. It does not state that they have to enroll yet.. just says that it is coming and to expect a letter.
MANDATORY ENROLLMENT PACKET - Sent by NY Medicaid Choice 30 days after the 1st "announcement" letter - stating recipient has 60 days to select a plan OR will be assigned to an MLTC plan. The first packets were sent in Manhattan in July 2012, telling them to select a plan by September 2012, later extended to October 2012. The Packet includes:
Form Letter to Personal Care/Home Attendant recipients (at this link with sample envelope) -- It also includes the toll-free number of the enrollment broker, NY Medicaid Choice, for consumers to call with questions about MLTC and help picking a plan..: 888-401-6582.
Official Guide to Managed Long Term Care, written and published by NY Medicaid Choice (Maximus)
List of Long Term Care Plans in New York City - 3 lists mailed in packet, available online - http://nymedicaidchoice.com/program-materials - NOTE: At this link, do NOT click on the plans listed as "Health Plans" - those are mainstream Medicaid managed care plans that are NOT for people with Medicare. Look for the "Long Term Care" plans for your area - NYC, Long Island, or Hudson Valley.
NYC lists -
CLICK HERE FOR TOOLS FOR CHOOSING AN MLTC PLAN.
CONTINUITY OF CARE -- One important factor in choosing a plan is whether you can keep your aide that worked with you when CASA/DSS, a CHHA, or a Lombardi program authorized your care before you enrolled in the MLTC plan. When MLTC began, the plans were required to contract with all of the home care agencies and Lombardi programs that had contracts with the local DSS for personal care/ home attendant services, and pay them the same rates paid by the local DSS in July 2012. That requirement ended March 1, 2014.
If you don't select and enroll in a plan, midway through the 60-day period to select a plan, you will receive a letter with the name of the MLTC plan to which you will be randomly assigned if you do not select a plan. You will still have til the third Friday of that month to select his/her own plan. For example, the first assignment letters to lower Manhattan residents were sent Oct. 2, 2012. If those individuals enrolled in a different plan by Oct. 19, 2012, their own selection would trump the auto-assignment, and they would be enrolled in their selected plan as of Nov. 1, 2012.
HOW DO I ENROLL IN A PLAN --
ONCE you select a plan, you can enroll either directly with the Plan, by signing their enrollment form, OR if you are selecting an MLTC Partially Capitated plan, you can enroll with NY Medicaid Choice. If you are selecting a Medicaid Advantage Plus (MAP) or PACE plan, you must enroll directly with the plan.
WHEN IS MY ENROLLMENT IN AN MLTC PLAN EFFECTIVE?
Enrollment in MLTC, MAP and PACE plans is always effective on the 1st of the month. The plan is paid its "capitation" rate or premium on a monthly basis, so enrollment is effective on the 1st of the month.
If you enrolled late in the month (after the third Friday of the month), the enrollment will not be effective -- and the new plan will not take charge of your care -- until the first of the second month after you enroll.
NEW APPLICANTS -- If you were not previously receiving Medicaid personal care, CDPAP, CHHA Lombardi, private duty nursing or adult day care program services --
Must request a Conflict-Free Eligibility assessment. Click here for more information.
TRANSITION RIGHTS - AFTER YOU ENROLL IN MLTC in NYC & Mandatory Counties - Right to Continue Past Services During 90-Day Transition Period, Assessment & Changes Made by Plan, Requesting new or Increased Services
What happens after you enroll depends on whether or not you were already receiving Medicaid home care, adult day care, home health aide, or other long-term care services before you enroll in the MLTC plan.
- PEOPLE WHO WERE RECEIVING CASA/DSS home attendant/ housekeeping/CDPAP/ or personal care, or CHHA, adult day care or LOMBARDI PROGRAM services -when they enrolled in an MLTC plan in NYC or another Mandatory County-
90-DAY TRANSITION PERIOD --The MLTC plan must provide the same services and the same number of hours as CASA/DSS/CHHA had authorized for 90 days.
This period was extended from 60 DAYS to 90 DAYS by directive of NYS Dept. of Health effective May 8, 2013. See MLTC Policy 13.10: Communication with Recipients Seeking Enrollment and Continuity of Care
The CMS Special Terms & Conditions states:
"Initial transition into MLTC from fee-for-service. Each enrollee who is receiving community-based long-term services and supports that qualifies for MLTC must continue to receive services under the enrollee's pre-existing service plan for at least 60 days after enrollment, or until a care assessment has been completed by the [MLTC], whichever is later."
During this 60-day transition period, which became a 90-day Period by directive of the State on May 8, 2013, by Day 30, the plan must assess the new members needs in her home. SOURCE: CMS Special Terms & Conditions 9/2012 sec.17(d)(ii)(1)(c)(p. 19). The plan’s nurse will decide how much care the plan will approve for after the 60-day transition period.
90-day transition applies to Lombardi program - see MLTC Policy 13.13: Continuity of Care and Payment Requirements of MLTC Plans to LTHHCP Agencies Providing Care During the 90 Day Transition Period
NOTICE OF A REDUCTION IN SERVICES AFTER TRANSITION PERIOD If the plan wants to reduce or end the services you previously received from CASA/DSS, or a CHHA, the plan must give you a WRITTEN NOTICE stating the amount of home care and other services they will give you effective on Day 61 (Day 91 after May 8, 2013) of your enrollment. The notice will explain your right to appeal. See this article re Appeals and Grievances in Managed Long Term Care for more information on your right to appeal. Note that you must first request an Internal Appeal within the plan, and then, if you lose, you will receive a notice from the plan explaining you have the right to request a Fair Hearing. You are entitled to continue receiving the old services, without any reduction until the internal appeal and then the hearing is decided.
HOW DOES THE PLAN ASSESS MY NEEDS? The Plan's nurse conducts an assessment using a standardized assessment tool, which was changed to the Uniform Assessment Tool (UAT) --
Before, assessment was by the SAAM -- MLTC Semi-Annual Assessment of Members (SAAM) Tool - version 2.5 -- Both tools collect demographic information, diagnosis, living arrangements, and functional abilities. This tool does not determine the number of hours. Most plans use their own proprietary "task" form to arrive at a number of articles. Consumer advocates are concerned that the State has not clearly required plans to provide personal care, CHHA and other services in the same amount, duration, and scope as is provided in the state-plan outside of MLTC. See standards and regulations that apply under NYS Medicaid for personal care, CHHA, consumer-directed personal assistance (CDPAP) and other home care services. The State issued these guidelines for "mainstream" Medicaid managed care plans, for people who have Medicaid but not Medicare, which began covering personal care services in August 2011 -- Guidelines for the Provision of Personal Care Services in Medicaid Managed Care. It is reported that these also are used for MLTC.
The Federal Medicaid statute requires that all managed care plans make services available to the same extent they are available to recipients of fee-for- service Medicaid. 42 U.S.C. § 1396b(m)(1)(A)(i); 42 C.F.R. §§ 438.210(a)(2) and (a) (4)(i). The NYS DOH Model Contract for MLTC Plans also includes this clause: “Managed care organizations may not define covered services more restrictively than the Medicaid Program."
All decisions by the plan as to which services to authorize and how much can be appealed. See Appeals & Greivances in Managed Long Term Care.
Both federal regulations at 42 CFR 438.210 and the NYS DOH Model Contract for MLTC Plans (Appendix K - section 3. "Service Authorizations) dictate the deadlines for the plan to give you a decision when you request new services or an increase in existing services, such as home care.
The contract uses these terms to explain these requests:
A Prior Authorization is a request by the Enrollee or provider on Enrollee’s behalf for a new service (whether for a new authorization period or within an existing authorization period) or a request to change a service as determined in the plan of care for a new authorization period.
A Concurrent Review is a request by an Enrollee or provider on Enrollee’s behalf for additional services (i.e., more of the same) that are currently authorized in the plan of care or for Medicaid covered home health care services following an inpatient admission.
EXPEDITED REQUEST -- In either of the above two types of requests, the member or provider may request that it be expedited - if the plan determines or the provider indicates that a delay would seriously jeopardize the enrollee’s life or health or ability to attain, maintain, or regain maximum function. If the plan denied the Enrollee’s request for an expedited review, the plan will handle as standard review.
DEADLINES FOR PLAN TO PROCESS -- Contract and 42 CFR 438.210 provide that Plan must decide and notify Enrollee of decision by phone and in writing as fast as the Enrollee’s condition requires but no more than:
a. Prior authorization
- Expedited - 3 business days from request for service, subject to extension described below.
- Standard – within 3 business days of receipt of necessary information, but no more than 14 calendar days of receipt of request for services, subject to extension described below.
b. Concurrent review
- Expedited – within 1 business day of receipt of necessary information, but no more than 3 business days of receipt of request for services, subject to extension described below.
- Standard – within 1 business day of receipt of necessary information, but no more than 14 calendar days of receipt of request for services, subject to extension described below.
- In a request for Medicaid covered home health care services following an inpatient admission, one (1) business day after receipt of necessary information; except when the day subsequent to the request for services falls on a weekend or holiday, seventy-two (72) hours after receipt of necessary information; but in any event, no more than three (3) business days after receipt of the request for services.
EXTENSION OF ABOVE DEADLINES including Expedited Requests -- Up to 14 calendar day extension may be requested by Enrollee or provider on Enrollee’s behalf (written or verbal). The plan also may initiate an extension if it can justify need for additional information and if the extension is in the Enrollee’s interest. In all cases, the extension reason must be well documented.
- The plan must give the enrollee written notice of the reason for the decision to extend the timeframe and inform the enrollee of the right to file a grievance if he or she disagrees with that decision; and Issue and carry out its determination as expeditiously as the enrollee's health condition requires and no later than the date the extension expires. 42 CFR 438.404(c).
If the plan does not issue a decision on a request for services within the timeframes specified in § 438.210(d) described above, this constitutes a denial and is thus an adverse action, which can be appealed just as a written decision can be appealed. 42 CF.R. 438.404(c)(5). See article on Appeal & Grievances in MLTC.
- CAN I CHANGE MLTC PLANS?
YES. You may change plans once a month. BUT the change will not take place until the 1st of the next month. If you enroll in a new plan after the third Friday of the month, you will not move to the new plan until the 1st of the SECOND month. So you will have to stay with your current plan until then.
Don’t sign up for a new plan unless the new plan confirms that it will approve the services you want and the hours you need. You may call any plan and request that they send a nurse to assess you and tell you what services they would provide. You have the right to receive the result of the assessment in writing.
- IF A PLAN CAN ONLY BEGIN SERVICES ON THE 1ST OF ANY MONTH, WHAT DO I DO IF I NEED SERVICES RIGHT AWAY WHEN I GET OUT OF THE HOSPITAL OR OUT OF A REHAB CENTER?
You may contact a Certified Home Health Agency (CHHA) and ask it to provide you with a home health aide and visiting nurse temporarily until you enroll in an MLTC plan. The CHHA may give short-term Medicaid home care for up to 120 days. During that time, you can select the type of plan you want and pick a plan that meets your needs. See above, under “What are the different types of plans to choose from” and “How to choose a Plan.” To find a CHHA that serves your county or borough, look on this online directory posted at http://homecare.nyhealth.gov/
- I HAVE A SPEND-DOWN (SURPLUS INCOME). WHAT HAPPENS IF I DON’T PAY IT? The MLTC plan will bill you for the spend-down. If you don’t pay it, the MLTC plan may disenroll you. If you live in NYC or another mandatory county, you will not be able to get Medicaid home care or other long-term care services.
MLTC's may Disenroll Member for Non-payment of Spend-down - The HRA home attendant vendors were prohibited by their contracts from stopping home care services for someone who did not pay their spend-down. Similarly, CHHA's are prohibited by state regulation from stopping services based on non-payment. FN 4. MLTC programs, however, are allowed to disenroll a member for non-payment of a spend-down. See model contract p. 15 Article V, Section D. 5(b). While the State's policy of permitting such disenrollment is questionable given that federal law requires only that medical expenses be incurred, and not paid, to meet the spend-down (42 CFR 435.831(d)), the State's policy and contracts now allow this disenrollment.
SPEND-DOWN TIP 1 --For this reason, enrollment in pooled or individual supplemental needs trusts is more important than ever to eliminate the spend-down and enable the enrollee to pay their living expenses with income deposited into the trust. For more information about pooled trusts see http://wnylc.com/health/entry/6/.
SPEND-DOWN TIP 2 - for new applicants who will have a Spend-Down - Request Provisional Medicaid Coverage -- When someone applies for Medicaid and is determined to have a spend-down or "excess income," Medicaid coverage does not become effective until they submit medical bills that meet the spend-down, according to complicated rules explained here and on the State's website. Many people applying for Medicaid to pay for long-term care services can't activate their Medicaid coverage until they actually begin receiving the services, because they don't have enough other medical bills that meet their spend-down. This creates a catch-22, because they cannot start receiving MLTC services until Medicaid is activated. If they apply and are determined eligible for Medicaid with a spend-down, but do not submit bills that meet their spend-down, the Medicaid computer is coded to show they are not eligible. As a result, an MLTC plan could refuse to enroll them -- because they do not have active Medicaid. To address this problem, HRA recently created a new eligibility code for "provisional" Medicaid coverage for people in this situation. This is explained in this Medicaid Alert dated July 12, 2012. Applicants who expect to have a spend-down should attach a copy of this Alert to their application and advocate to make sure that their case is properly coded.
The New Housing Disregard - Higher Income Allowed for Nursing Home or Adult Home Residents to Leave the Nursing Home by Enrolling in MLTC
See this article
For the latest on implementation of MLTC in 2013 see these news articles:
MLTC Roll-Out - Expansion to Nassau, Suffolk & Westchester / and to CHHA, Adult Day Care and Private Duty Nursing in NYC (update 1/25/13 - more details about transition to MLTC)
For more information please see:
Applying for Medicaid Personal Care Services in New York City - BIG CHANGES SEPTEMBER 2012 - explains new procedures in NYC
New York Medicaid Choice (Maximus) Website - this is State Enrollment Broker - under contract with NYS to handle all mandatory enrollment into MLTC and in Mainstream Medicaid managed care
NYC HRA Medicaid Alert dated July 3, 2012 from NYC HRA explaining this first step in mandatory MLTC.enrollment.
MLTC Semi-Annual Assessment of Members (SAAM) Tool - version 2.5 (PDF, 179KB, 24pg.)
Consumer Concerns on Mandatory Enrollment in Managed Long Term Care
In August 2012, a letter was sent from The Legal Aid Society, Empire Justice Center, NYLAG, CIDNY, and other consumer, disability rights and community-based organizations asking for further protections in rolling out MLTC. Consumers ask that MLTC be rolled out more gradually, so that it starts with new applicants seeking home care only, rather the tens of thousands of people already receiving personal care/home attendant services. Consumers also express concerns about appeal rights being limited if and when MLTC plans reduce services compared to what the individual previously received from the Medicaid program. See the letter for other issues.
In March 2012, consumer advocacy organizations proposed Incentives for Community-Based Services and Supports in Medicaid Managed Long TermCare: Consumer Advocate Recommendations for New York State.
On December 27, 2011, Legal Aid Society, New York Lawyers for the Public Interest, and many other organizations expressed concerns to CMS in this letter. These concerns include violations of due process in fair hearing appeals.
On May 2, 2011, Selfhelp Community Services led numerous organizations in submitting these comments, explaining numerous concerns about the expansion of MLTC
The Long Term Care Community Coalition published Transition To Mandatory Managed Long Term Care: The Need for Increased State Oversight - Brief for Policy Makers. and other information on its MLTC website.
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