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MLTC UPDATE: Guildnet Closing Letters Sent to 7500+ Members - Learn Tips at NYLAG CLE on Nov. 14th, Nursing Home Changes in MLTC

29 Oct, 2018

This is a running news article with updates on Managed Long Term Care in NYS. 

 Please see archives for past articles:

KEY CONTACTS

October - Nov 2018 Update -

1.    Upcoming Training & CLE  Program on Managed Long Term Care - Nov. 14, 2018 at the New York Academy of Medicine. Click here for registration information.   Conducted by NYLAG Evelyn Frank Legal Resources Program.  CEU and CLE credits available  Come to learn about the many changes described in this October 2018 update, 

2.     Guildnet  MLTC and 4 FIDA Plans Closing  - As reported in the September update, Guildnet is closing and 4 FIDA Plans are closing Jan. 1, 2019

  • GUILDNET MLTCThis notice was sent by New York Medicaid Choice to all Guildnet MLTC members  on Oct. 19, 2018, stating that if they don't select a new plan by 12/19/2018  they will be auto-assigned to a new plan for January 1st.  The notice states, "The Plan you select will continue to honor your current plan of care  for 120 days from the  date that you transfer to the new plan."   These "transition rights" were authorized by the NYS DOH MLTC Policy 17.02  which requires continuity of care in the new plan after a plan closing.  For Guildnet FIDA, See item #3 below.

  • A few notes about the Guildnet closing and some tips: 

    • The notice doesn't include contact information for ICAN, the statewide Ombudsprogram to advocate for MLTC members.  That is  TEL 844-614-8800     TTY Relay Service:  711   Website:   icannys.org      ican@cssny.org

    • Warning:  Ten percent of Guildnet MLTC members already transferred to other plans from Sept. to Oct. 2018.   See  enrollment chart.    If the new plan has reduced services, we suggest you request a PLAN APPEAL with AID CONTINUING, and contact ICAN for help, and file a complaint with the NYS Dept. of Health.  1-866-712-7197  or  e-mail mltctac@health.ny.gov.    While it is not clear in DOH Policy 17.02  that those who transferred before the 10/19/18 letter was sent by NY Medicaid Choice are entitled to the 120-day continuity of care, we believe that they are.  

  • Priority of Keeping Member's Long-time Home Care Workers.  One key factor in selecting a new plan is to pick one that contracts with the same Licensed Home Care Services Agency (LHCSA) or CDPAP Fiscal Intermediary through which the member has  her home care aides.   Please note that another change that went into effect October 1, 2018 is that MLTC plans were required to reduce the number of their contracts with LHCSAs, which means that many MLTC members may be losing a long-time aide.   It is therefore critical to find a plan that will enable the client to maintain a longtime trusted aide.  This change is described here, with links to relevant documents, including the DOH guidance posted in August 2018.

  • Another factor in selecting a plan is that the plan will continue the same hours that Guildnet has authorized after the end of the 120-day transition period, during which the new plan must continue the old hours.  While this would be desirable to  confirm to prevent the need for appeals down the road,  it may not be possible to obtain a plan's commitment to continue this amount of hours.  Therefore, we suggest that once you identify a plan that contracts with the same home care provider agency, that  the member contact  NY Medicaid Choice and request to be enrolled in that plan.  Under Policy 17.02, they do not  have to be assessed by the new plan.. It says,

"... NYMC will subsequently process the enrollment transaction to the receiving plan.....The new plan must accept the transfer enrollment of all enrollees that select the plan. These transferring enrollees are presumed to meet the eligibility requirements for MLTC and are not required to be assessed prior to enrollment."

They might do this between November 20th and December 19th, so that the new plan enrollment will begin January 1, 2019.  After that, the plan must continue the same plan of care for 120 days.

  • MLTC members - What happens after 120 days? [FIDA - 90 days, see more below]  The new plan must conduct an assessment within 30 days, but may not reduce hours until after the 120 days.  While Policy 17.02 does not say, another policy clearly limits plans from reducing hours, unless there is a specific change in the enrollee's condition or circumstances since the original plan of care was authorized, and that fewer hours are needed because of that change.  Please review MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services.  This guidance provides explicit limitations on when plans may reduce hours, and applies to the new plan to which a member transfers when an old plan closes.   If plan claims a justification for reduction, it must send  Notice of Reduction at least days before the proposed effective date of the reduction, with the right to request a plan appeal (internal appeal), with  Aid Continuing if the appeal is requested before the effective date.  See more about the new plan appeal or exhaustion requirements here

    • Get Case Record from Guildnet.  Especially for consumers receiving 10+ hours/day or 24/7 care, they should request from Guildnet now, before they are transitioned, copies of their case record, including at least the last  biannual Uniform Assessment System (UAS) assessments, and the last two authorizations or notices authorizing their current plan of care.   If they've received the current plan of care for a longer period of time, they might request these documents going back to the first time that Guildnet authorized their current plan of care.   These records may be useful if a new plan tries to reduce hours.  

    • How to request records:   The  MLTC Enrollee Rights that is contained in every MLTC plan  model contract states in part, "You have the Right to get a copy of your medical records and ask that the records be amended or corrected."  See model contract Appendix L (p. 153 of PDF) This right is also in the NYS DOH Managed Long Term Care Consumer guide, available here  (see p. 17), and in all plan member handbooks. We are finding out the best way to request records.   Until further information is available, we suggest emailing it to  gnprovrel@jgb.org or mailing it to GuildNet Member Services 250 West 57th Street 10th floor New York, NY 10107  or call Member Services at New York City: 212-769-7855      Brooklyn: 718-495-2200       Toll Free: 800-932-4703 

    • If you  want your records to be released to a representative or anyone other than you, include a HIPPA release - OCA Form No. 960 - Authorization for Release of Health Information Pursuant to HIPAA

  • If a Guildnet member arranges to be assessed by a new plan, whether referred by NY Medicaid Choice or by the member reached out to a  new plan, and the new plan says they would give fewer hours than Guildnet had authorized, the individual should not sign anything that might be interpreted as agreeing to this reduced plan of care.   If they do sign an enrollment agreement,  or even sign a reduced plan of care, we believe advocacy can be done to protect the member's rights to continuity of care under Policy 17.02.  However, this will likely require advocacy once they transfer.

Under Policy 17.02 quoted above, a Guildnet member who calls NY Medicaid Choice may ask NYMC to directly enroll them in a particular plan of their choice, without signing any enrollment agreement.  If  they call NYMC  and NYMC refers them to contact a plan to be assessed, they can cite Poilcy 17.02 and say that they prefer to be directly enrolled into the selected plan.  

  • LOCK IN - If member is unhappy with their new plan, may they change plans?   Think  twice before changing plans again for two reasons. 
    • NEW LOCK IN RULES -  If hey change to the new plan on December 1st or later, new "lock-in" rules go into effect.  These will allow MLTC members to change plans only in the first 90 days after enrollment.  After, that they are locked in for the next nine months  and may only change plans  for good cause.   This change has not yet been approved by CMS  as of Oct. 29, 2018 so it may not go into effect on December 1st as the State has proposed.   Here is the proposed notice DOH will send to all MLTC members explaining the new lock-in rule. 

    • Second, if the member changes plans again, State policy has been that changing plans a second time after a plan closing is a "voluntary" change, so the 2nd plan is not required to give the 120-day continuity rights.  The State's view is that the enrollee has agreed to the plan's plan of care and number of hours of service, so has agreed to any reduction of hours that entails.  Advocates may disagree with this policy, which may be subject to challenge,  but as of now this is the State's policy.    ​​​​​​​

  1. FIDA CLOSINGS -  Four FIDA plans are also closing in January 2019:  
    1. Guildnet GoldPlus FIDA plan -    NYC only (418 members) 
    2. Village Care Max Full Advantage   NYC only  (   23 members)
    3. MetroPlus FIDA                              NYC only   (205 members)
    4. AgeWell NY FIDA plan  -                NYC, Suffolk, Nassau, & Westchester (247 members) --          NOTE that Agewell was the SOLE FIDA plan in Suffolk county.
  • GUILDNET FIDA - These notices were sent by Guildnet and by New York Medicaid Choice to all Guildnet Gold Plus FIDA plan members in early October 2018, stating that if they don't select a new plan by 12/31/18, they will be auto-assigned to Healthfirst AbsoluteCare FIDA plan for January 1st.  As the notices state, consumers who are assigned to Healthfirst FIDA have transition rights to continue receiving services, including homcare, at their current levels for 90 days. 

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 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).

For plan options see the NY Medicaid Choice website:

Long Term Care Plans in Long Island

Long Term Care Plans in Hudson Valley

Long Term Care Plans in New York City

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.

  1.   Exclusion of Nursing Home  Residents from MLTC plans.   In late September,   September 2018, NYS DOH submitted a request to CMS to amend the 1115 waiver to exclude permanent nursing home residents from MLTC enrollment after 3 months.  The  State's proposal and accompanying documents are posted on the State's MRT webpage here.   This is a reversal of the policy in effect since 2015, described in this article.

NYLAG's comments on the rule state that the "clock" should not start ticking toward  three months until disenrollment if the member intends to return home.  Disenrollment will make it much harder to return home.   The proposed procedures do state that the period in which Medicare is covering all or part of a rehab stay will not count toward the 3 months of permanent placement.   Also, NYLAG and other consumer advocates urged that plans must give notice of a decision to consider them "permanently placed," which the consumer should have the right to appeal.   These decisions must be made with involvement of the consumer, not unilaterally by a managed care plan or nursing home. 

The comment period to submit comments to the State on this proposal is  open until November 23, 2018.  Comments can be submitted via email to mltcinfo@health.ny.gov. In the subject line please indicate Proposed NH Benefit/Lock In 1115 Amendment Comments.   

September 2018 Update -

1.    Upcoming Training & CLE  Program on Managed Long Term Care - Nov. 14, 2018 at the New York Academy of Medicine. Click here for registration information.   Conducted by NYLAG Evelyn Frank Legal Resources Program

2.   The NYS Dept. of Health has confirmed that GUILDNET will  CLOSE in JANUARY 2019; UnitedHealthCare is pulling out of 4 upstate counties in February 2019:

  • 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
  • UnitedHealthcare is no longer offering their partial-capitation MLTC plan in the following counties effective 2/1/2019, shown with enrollment as of AUGUST 2018:

ALBANY 103
BROOME 266
ERIE 181
MONROE 534
ONEIDA 91
ONONDAGA 288
Total 1,463
  • In both cases, per MLTC Policy 17.02, enrollees will receive advance 60-day written notice of the change, with an opportunity to choose a new plan before the effective date. or if they do not choose a new plan, they will be auto-assigned to a new plan effective Jan. 1, 2019.

    • Guildnet enrollees will receive notice the week of 10/15/2018, and must choose a new plan by 12/19/2018 to avoid auto-assignment.  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). 

      • WARNING:  Please note that it is not clear exactly what date NY Medicaid Choice will begin doing "warm transfers," without a CFEEC.  Until clarification is received, we advise Guildnet members to remain in Guildnet until they receive the letter in mid-October explaining their options.

    • UHC enrollees will receive notice in November regarding the plans closing effective Feb. 1, 2019; details to come

    • DOH said that Guldnet MLTC and UHC members will be randomly auto-assigned to a different plan if they do not select one by the deadline.  However, DOH indicated that NY Medicaid Choice will conduct outreach with members to try to assign the member to a plan with the same licensed home care agency (LHCSA) in its network to promote continuity of care.  FIDA auto-assignments will be fully “intelligent” based on Primary Care Provider and LHCSA.

  • Transition Rights - Continuity of Care -- These transitions are covered by MLTC Policy 17.02, with the following consequences:

    • The new plan must continue to honor the same service plan with the same providers and same amount of home care and other services for 120 days after the effective date, "or until the new plan has conducted an assessment and the enrollee has agreed to the new plan of care."

    • This is true whether the enrollee chooses their own plan before 12/19 or allows themselves to be autoassigned.  However, it is not clear whether members have this protection YET.   We are waiting for clarification about whether members who already are switching to another plan effective October 1st are protected by these continuity protections.  Until this is confirmed,  members should STAY IN THEIR CURRENT PLAN and wait for official notice before they switch plans.  

    • Those who call NYMC before 12/19 to choose their plan will be able to do a “blind enrollment” (no pre-enrollment conflict-free assessment)  Again, it is not clear whether members  can do this now, or must wait til after Oct. notices go out to Guildnet members.  Until this is clarified, we suggest that they remain in their current plan.

  • 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

    • Guildnet enrollees will have 90 days from the effective date of their enrollment into a new plan, if on 12/1/18 or later, to switch plans (e.g., if they don’t like the plan they were autoassigned to)

    • After the 90 days, they will be locked into their plan for 9 months unless they can establish good cause

3.   POLICY ISSUED IMPLEMENTING restriction on the number of Licensed Home Care Services Agencies that an MLTC plan may contract with, beginning Oct. 2018.  

  • The budget change is described here, with links to relevant documents.
  • The DOH guidance posted in August 2018 sets forth an Exception process:

    "An MLTC plan may request an exception targeted to specific patient needs. These include, as set forth below, continuity of service with a particular LHCSA or aide, to avoid disruption of service where geographic hardship exists or the region is otherwise hard to serve, or for the purpose of ensuring cultural or linguistic competencies."  In part, if a plan stops contracting with one LHCSA to comply with the new limits, and an  "enrollee wishes to be cared for by one or more home care workers employed by the current LHCSA, the MLTC plan may continue contracting with the current LHCSA for the purpose of continuing that enrollee´s care by those home care workers for up to three months."  MLTC plans must notify DOH at LHCSAExceptions@health.ny.gov of the three–month extension of the LHCSA agreement.  The guidance does not explain how an enrollee may request this extension.  

  • "An MLTC plan may request an exception to the maximum number of allowable contracts by demonstrating, to DOH´s satisfaction, that additional contracts are needed to ensure adequate access to services in a geographic area. Adequate access to services includes special needs services and services that are culturally or linguistically appropriate."  Again, the guidance does not explain how an enrollee may request that the MLTC plan request an exception.

August 2018 Update

  • On Aug. 21, 2018, the CEO of Guildnet sent a letter to all Guildnet employees stating that its Board of Directors had decided the previous day to close Guildnet effective 12/1/18. The letter (posted here)  states that the plan will be working closely with the State Dept. of Health on the transition of its members to other MLTC plans.  On August 28, 2018, Crain's NY Business reported that the NYS Dept. of Health (DOH) confirmed that "GuildNet had filed a request with the state to stop offering its MLTC plan. It said the nonprofit has stopped enrolling new members. 'The department is working with GuildNet to ensure continuity of care as it finalizes particulars of this plan,' a spokeswoman said."   See this article which explains member "transition rights" when an MLTC plan closes.  It is very important that members do not panic and switch to other plans until there is official notice from the State.  People who switch plans now will not be protected with "transition rights" under  MLTC Policy 17.02  that is described here.   Read about consumer advocates' concerns about the State's transition policy here.  As of August 2018,   Guildnet has 7,316 MLTC Members in its MLTC plan,  478 in its Medicaid Advantage Plus plan, and 417 in its FIDA plan - all in NYC.  Crain's implies that all three plans are closing but this has not been confirmed.  Guildnet's enrollment has markedly decreased in the last year or two,  from being the second largest MLTC plan in NYC to the 10th largest plan currently. See this chart.   Read more about the Transition Policy when plans close here.

July 2018 Update

  • NEWS OUTLETS REPORT POTENTIAL CLOSING OF INDEPENDENCE CARE SYSTEMS (ICS) MLTC PLAN later in 2018.  See this article, with advice given by ICS in a memo  to its Member Council, "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 "continuity of care" refers to the right of members of plans that close to receive their same plan of care  for 120 days after they transfer to a new plan, under NYS DOH  "MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration." 
  • NYS LEGISLATURE ENACTS CHANGES IN MLTC IN STATE BUDGET.  The NYS Dept. of Health is now preparing to implement various changes in the MLTC program that were enacted in the NYS Budget in April 2018.   

    • Beginning December 2018, MLTC members will no longer be able to switch plans after a 3-month grace period after their enrollment.  See this article for more about this change.

    • MLTC members who are  permanently placed in a nursing home for more than 3 months will be disenrolled from the MLTC plans.  . 

    • Read about  these and other MLTC changes in this article.  

  • The new requirement to request an internal Plan Appeal of an  Initial Adverse Determination of a managed care or MLTC plan, before one may request a Fair Hearing, began May 1, 2018.  See more about these changes here.   Find a link to watch a recorded webinar about these changes here.  

March 27, 2018 update

  • The NYS Dept. of Health now has web pages for both MLTC and Mainstream Managed Care plans about the new "exhaustion" requirement -- members must now first appeal decisions of the plans in an internal "plan appeal" before requesting a fair hearing.   For links to these pages, and to learn about webinars sponsored by the NYS Dept. of Health and by NYLAG Evelyn Frank Legal Resources Program about the changes, click here

  • The final NYS budget is anxiously anticipated, with the legislature hoping to have it completed before March 30th, ahead of the weekend and Passover and Easter travel.  To read about some of  the proposals that affect Managed Long Term Care and Medicaid recipients generally,  see this article.

February 28, 2018 update

  • On Feb. 27, 2018, the starting date for the new requirements that MLTC member request Internal Appeals with their MLTC plans before requesting a Fair Hearing has been pushed back to May 1, 2018, from April 1,  2018.  See this news article for information on the changes, and also this article that explains the new rules in more detail. 

​December 2017 Update

October 26, 2017 Update on Home Care Worker Pay issues

An update to the news below about the recent NYS Appellate Division decisions that allow lawsuits to go forward by home care aides challenging a 2010 NYS Dept. of Labor policy that allows live-in aides to be paid only 13 hours/day.  The courts found that the 2010 policy  is contrary to the state labor regulations that require that the minimum wage be paid for every hour worked, unless the worker actually resides in the consumer's  home.

On Oct. 25, 2017, the NYS Dept. of Labor published an "emergency regulation" (p. 5 of link) that amends the NYS minimum wage regulations in a way that appears to attempt to undermine the recent appellate court decisions.  Those decisions found that the 2010 NYS Dept. of Labor policy RO-09-0169 Live-In Companionsthat  allowed live-in aides to be paid 13 hours for a 24-hour day, if they do not actually live with the consumer, conflicted with the actual state minimum wage regulations.  Now the State amended the minimum wage regulations to state that live-in aides need not be paid for the 3 1-hour meal periods and 8 hours of sleep time (totaling 11 hours/day) that are excluded from hours worked under the federal minimum wage regulations as amended by the Obama administration.  The amendments appear to be intended to adopt the 2010 policy guidance  RO-09-0169 Live-In Companionsand allow payment of 13 hours/day..  If the Court of Appeals accepts review of the Appellate Division cases, the impact of the regulatory amendments will no doubt be disputed.  In the meantime, it is not clear what is the impact of the amendment to the regulations.  See consumer advocacy tips below if consumer's 24-hour shift is not staffed adequately by an MLTC plan or managed care plan.   

August - October 2017 Update

MLTC Plan Closings Update 

  • The NYS Department of Health has finally issued a Transition policy that gives some protection to members of plans that close.   "MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration." issued 9/22/17,  has 2 key protections:  

    1. Members of a closing plan will receive  a notice from New York Medicaid Choice, the States enrollment broker for managed care, that  if they do not select a new plan within sixty (60) days, they will be auto–assigned to a new MLTC plan.  

    2. The new plan must continue the same services provided by the closing plan for the longer of 120 days or until the member "agrees" to a new service plan.  See more about this policy and Advocacy concerns in this article.   

The new MLTC Policy 17.02 procedures will be used for Guildnet and North Shore LIJ Closings described below.

  • ​Guildnet - About 3,000 former members of Guildnet MLTC plan in  Long Island and  Westchester who transitioned to another plan after they heard Guildnet was closing, have received this  Sept. 29, 2017 letter from the State telling them they  may request that their hours be restored to the amount Guildnet authorized, if the new plan reduced their hours.  To request that hours be restore, they must call New York Medicaid Choice before Dec. 29, 2017 at 1-888-401-MLTC or 1-888-401-6582.   If they are still eligible for Medicaid, the new plan should  increase their hours to the amount Guildnet authorized.   If you have called NY Medicaid Choice and cannot get your former hours restored to the amount Guildnet gave, you can call NYLAG Special Litigation Unit at 212-613-5032 or call ICAN Ombudsprogram at 1-844-614-8800 

    • The remaining 930 Guildnet members in  Nassau, Suffolk  & Westchester counties will received in mid-October that they have 60 days to select a new plan, or they will be auto-assigned to another plan The new plan must continue the same services that Guildnet provided for 120 days or until the member agrees to a change.

    • See more about the Transition Policy, status of plan closings, and  SUGGESTED CONSUMER STRATEGIES to protect consumers from reductions in hours in this transition in this article.  

Two New FIDA Plans Launched in Westchester, while 5 FIDA Plans Slated to Close in 2018 

When FIDA first expanded outside of New York City and Nassau counties to Westchester and Suffolk, only one plan -- Agewell FIDA -- was offered in those counties.  Two new FIDA plans  are available in Westchester County (since 7/1/17) -- Healthfirst and Riverspring.  Agewell remains the only plan available in Suffolk.  See complete list of FIDA plans , but note that the list will change in 2018 when these 5 FIDA plans close: Aetna, Guildnet (in Nassau County only), Fidelis, ICS, and North Shore -LIJ, 

  • Lists of all MLTC, Medicaid Advantage Plus, PACE and FIDA  plans by region is available on NY Medicaid Choice website. (Scroll down to Health Plan Lists)(Note that FIDA list will change in 2018).  

Home Care Aide Wages - Court Decisions, Wage Parity and Minimum Wage increases - 

The million (or billion?) dollar question is how State will fund the additional pay for live-in workers in MLTC, mainstream managed care, CHHA, and in fee-for-service home care authorized by local Medicaid districts as "immediate need" services or for people excluded or exempt from MLTC or managed care.   Consumers are seeing ripple effects of the ruling in home care agencies refusing to accept new "live in" cases.   While rulings may be appealed, the decisions are not "stayed" and are arguably the binding interpretation of the law in NYC and the entire metro area covering about 12 other counties.  
Meanwhile, it remains difficult for consumers to obtain authorizations from MLTC plans for split shift or 2-12 hour shifts/day, despite helpful clarification of the standard for split shift "continuous" care  in state regulations, and despite helpful MLTC Policy 16.07.   See more on standards for assessing and authorizing personal care here. 
October 26, 2017 Update - See above for news about change in state labor regulations published Oct. 25, 2017. 
ADVOCACY TIPS --  Members of MLTC  or other managed care plans can file a grievance with your MLTC or managed plan and file a complaint with the NYS Dept. of Health  if you are authorized for 24-hour live in care but the MLTC or managed care plan cannot find an agency to staff the case.     

MORE TIPS:  Also, consider whether your needs may meet the standards for 2x12 split shift care, and request the plan to increase your services.  Call ICAN for help or guidance. 

Heads Up re Assisted Living Program (ALP) and MLTC - The Assisted Living Program is expected to be "carved into" MLTC and Mainstream MMC, effective 10/1/18 for NYC, Long Island and Westchester, and effective 1/1/19 for the rest of the state.  This means plans will now authorize and pay for ALP services, as they do nursing homes.  Exact procedures are unknown, but we presume that current ALP residents will be "grandfathered in" as nursing home residents were grandfathered in when the nursing home benefit was carved into MLTC.  See this article and MRT 1458

U.S. Office of Inspector General releases report,  "New York State Improperly Claimed Medicaid Reimbursement for Some Managed Long-Term Care Payments" (A-02-15-01026) -   

From executive summary:

New York improperly claimed reimbursement for 36 of 100 payments made to Medicaid Managed Long-Term Care (MLTC) plans. Specifically, New York did not ensure that MLTC plans documented eligibility assessments of program applicants and reassessments of those already in the program, and conducted these assessments in a timely manner. New York also did not ensure that the plans provided services to beneficiaries according to a written care plan. Further, New York did not ensure that the plans enrolled and retained only those beneficiaries who required community-based services, and disenrolled beneficiaries who requested disenrollment in a timely manner.

In addition, CMS physicians found that for 71 beneficiaries associated with the payments we reviewed, the beneficiaries' MLTC plans did not comply with New York's contract requirements for service planning and care management.

May 2017 UPDATE

  • HomeFirst, an MLTC plan run by ElderPlan, announced it is also pulling out of Suffolk County. As reported in Crain's Health Pulse, this is  "... the latest example of an insurer narrowing its geographic coverage for chronically ill and disabled members, the health  plan confirmed on Friday. The decision 'was driven by the difficulties we encountered effectively staffing and serving the needs of members across such an expansive geographic area,' said a spokeswoman for the nonprofit MJHS, which runs Elderplan. The insurer will continue to cover members' services until they pick a new plan, she said.

    Crain's further reported, "The move follows the exit of another nonprofit managed long-term care plan, GuildNet, from Suffolk as well as Nassau and Westchester counties as of June 1. The two plans had covered 41% of the 5,735 managed long-term care enrollees in Suffolk County as of March. The state Department of Health is "closely tracking" the transition of members in Suffolk County following the exits of GuildNet and Elderplan, a spokeswoman told Crain's.  There are still 10 plans offering coverage in the county, including Fidelis Care and North Shore-LIJ Health Plan. Earlier this month in response to GuildNet's exit, the department had said there was "ample capacity and choice" in the managed long-term care program."

  • Guildnet Withdrawal from Nassau, Suffolk and Westchester - On May 13, 2017, NYS Dept. of Health sent over 4000 letters to members of Guildnet MLTC plan in 3 counties - Nassau, Suffolk and Westchester, clarifying information sent by Guildnet in April. (See April 2017 update below).  The State Health Dept. clarified that members are not required to find a new plan by June 1st, and may remain in Guildnet after that date, and that Guildnet is required to continue providing them with MLTC services.   The letter does confirm that this MLTC plan has requested to stop providing services in these 3 counties.   However, the letter states Guildnet must continue providing services "until a smooth transfer can be completed to your new plan."  Still not specified is what happens if the individual cannot find a plan willing to provide the same hours as Guildnet authorized.  Advocates maintain that members have the right to continue the same amount of services.   See letter posted here 

The letter gives contact information for  ICAN - OMBUDSPROGRAM FOR FIDA & MLTC    Phone:  844-614-8800    TTY Relay Service:  711   Website:   icannys.org      ican@cssny.org

April 2017 UPDATE

  • Guildnet notified members in Nassau, Suffolk and Westchester that its MLTC "...will no longer offer Managed Long Term Care (MLTC) services" in these counties "effective June 1, 2017.”  The notice sent in late March further states, “It is important that you select a new MLTC plan before May 18, 2017 to assure a smooth transfer to your new plan."   Download a copy of the notice sent to Guildnet's over 4000 members in these 3 counties.  Here's more info about this change:
    • The letter further states, "You will continue to  receive services from GuildNet until your transfer to your new plan is complete." Advocates are informed that members WILL CONTINUE to receive Guildnet MLTC services even after June 1, 2017 if they do not select a new plan. 

    • Members will not be "auto-assigned" to a new MLTC plan if they do not enroll in one on their own. 

    • Despite the letter's wording, advocates are informed that if other MLTC plans do not authorize the same amount or type of services that the member now receives from Guildnet, they do not have to change plans.  Also, many MLTC plans are backed up and cannot schedule assessment visits until June or later.  Members may stay in Guildnet after June 1, 2017.  This is true regardless of what members may be told by staff of Guildnet, New York Medicaid Choice, or other organizations.

    • Also, some members have been notified that Guildnet will no longer contract with the home care agency that employs their home care worker.   Advocates were told by the State Dept. of Health that Guildnet must do "single case"  agreements with home care agencies.  This means Guildnet will still pay the home care agency to continue to provide services to individual members after June 1st,   even if that home care agency's contract with Guildnet ends on June 1st.   

    • The Guildnet Gold Plus FIDA Plan continues to be offered in Nassau County and Guildnet Medicaid Advantage Plus (MAP) Plans continue in Nassau and Suffolk Counties

    • Transition Policy Requested.  Advocates are asking the State to require the new plans (to which former Guildnet members are transferring) to continue the same services and same number of hours that Guildnet authorized.  So far, the State has not agreed to issue this "transition policy."  Transition policies require MLTC plans to continue the same services for 90 days that the consumer received before enrolling in MLTC, when the consumers are mandated to transition from fee-for-service personal care or CDPAP to MLTC.  See, e.g. MLTC Policy 13.13, MLTC Policy 13.01 (revised)(period was later extended from 60 to 90 days in MLTC Policy 13.10) (All MLTC policy directives available at https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm).  The same protection should apply in this situation, where a plan is effectively closing down.  Advocates contend that the new plan should only be allowed to reduce services below the amount Guildnet had authorized if there is a change in the member's needs or circumstances, after giving proper advance notice of hearing rights. See MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services

    • The Guildnet letter does not give contact information for ICAN - the Independent Consumer Advocacy Network that contracts with the State Dept. of Health to provide information and advocacy for consumers about MLTC, FIDA, and  other managed care plans.  Members with questions or who have problems keeping the same hours, or facing disruptions in their care should call ICAN.   Phone:  844-614-8800  
      TTY Relay Service:  711   Website:   icannys.org    e-mail:  ican@cssny.org

    • Who IS AFFECTED – as of March 2017 - as shown in this chart comparing with Nov. 2016 enrollment, based on DOH enrollment data
      • 35% of all 5,735 MLTC members in SUFFOLK  (1,990 members)
      • 27% of  6,438 MLTC members in NASSAU (1,753 members) 
      • 10%  of 4,685 MLTC members in WESTCHESTER  (451 members)
    • Background - In November 2016, as reported in the NYLAG MLTC news update article, Guildnet notified the State Dept. of Health that it "will no longer enroll members in Nassau, Suffolk and Westchester counties, according to a letter its chief sent to the state Department of Health.  Alan Morse, CEO of GuildNet, told the Cuomo administration the 'calamitous state of reimbursement' made it no longer feasible to operate because the program was incurring 'substantial deficits.'"   See story reported in Politico dated Nov. 23, 2016.   On January 13, 2017, Crain's Health Pulse reported that Guildnet announced that it would hold off on giving the State the formal 90-day notice required before it exited from any counties.  Crain's quoted Alan Morse, the CEO of Guildnet, "We said we would hold off on giving them formal notice until we figured out how well they would address our needs and how we're going to make the program work," with Mr. Morse referencing MLTC reimbursement rates.

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