MLTC UPDATE 2018 - Prepare for May 1, 2018 Changes in Fair Hearing Appeal Rights
27 Feb, 2018
This is a running news article with updates on Managed Long Term Care in NYS.
Please see archives for past articles:
State Dept. of Health Complaint Number for MLTC Problems - 1-866-712-7197 or
- Request Conflict-Free MLTC Assessment - needed to enroll in an MLTC plan
FIDA - call NY MEDICAID CHOICE at 1-855-600-3432 (1-855-600-FIDA) Fax 1-917-228-8601
For MLTC enrollment complaints - call NY Medicaid Choice -
ICAN - OMBUDSPROGRAM FOR FIDA & MLTC Phone: 844-614-8800
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
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 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.
North Shore LIJ MLTC - New York Newsday publicized the closing on September 1, 2017, Northwell to end long-term care plan that covers 6,000 elderly, On September 22, 2017, North Shore sent this letter to all of its 5,645 members in Nassau, Suffolk, and New York City. The letter informs members that the plan is closing 12/31/17. and that unless they enroll in a different plan before 11/10/17, they will be auto-assigned to Centers Plan for Health Living effective January 1, 2018. While the letter does not specifically say it, North Shore LIJ members should have the protections regarding keeping their same services, described above in new DOH MLTC Policy 17.02. See this article for more about the policy, advocate concerns about the policy, and consumer strategies to ensure that services are not reduced in the transition. If hours were or are cut when they transfer to a different plan, call NYLAG Special Litigation Unit at 212-613-5032 or call ICAN Ombudsprogram at 1-844-614-8800
See more about plan closings here, including which FIDA plans will be closing in January 2018
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,
Home Care Aide Wages - Court Decisions, Wage Parity and Minimum Wage increases -
Home care workers, including CDPAP personal assistants, are entitled to increases in wages in 2017, with further increases in 2018. See
Appellate Division decisions strike down state rule that allows 24-hour live-in aides to be paid only 13 hours/day. Decisions state that 24-hour case home care workers must be paid for all 24 hours if they are “nonresidential,” meaning they do not exclusively reside in the consumer's home. The decisions were based, in part, on rejecting a 2010 state Dept. of Labor policy guideline RO-09-0169 Live-In Companionsas in conflict with state minimum wage regulations. Tokhtaman v. Human Care, LLC (1st Dept. 2017 NY Slip Op 02759); Andreyeva v. NY Home Att. Agency; Moreno v Future Care Health Serv. (2nd Dept.)
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.
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 firstname.lastname@example.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: email@example.com
- 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.
Please see archives for past articles: