A type of private managed care plan that is a combination of a Medicare Advantage plan and a Medicaid managed care plan. These plans cover all services under Medicare Parts A, B, & D, as well as almost all services covered under Fee-For-Service Medicaid in New York, with the exception of personal care, CDPAP, mental health, and adult day health care. This type of plan is always optional. It may make sense for dual eligibles who do not require long-term care services.
Medicaid Advantage Plus - This is a type of managed care plan that includes virtually all services covered under Medicare and Medicaid. It is like a Medicare Advantage plan merged with a Medicaid managed care plan and an MLTC plan. It covers everything included in Medicaid Advantage, plus all MLTC services. This is one option for dual eligibles who are in need of LTC services and thereby required to enroll in MLTC (the other two are partial-cap MLTC and PACE). Otherwise, it is voluntary.
The acronym MAP is also used to refer to the Medical Assistance Program in New York (in other words, Medicaid).
Program of All-inclusive Care for the Elderly - A PACE is a type of fully-capitated MLTC plan that provides a comprehensive system of health care services for members age 55 and older who are otherwise eligible for nursing home admission. Both Medicare and Medicaid pay for PACE services (on a capitated basis). PACE members are required to use physicians & providers employed by or contracted with their plan. An interdisciplinary team develops care plans and provides on-going care management. The PACE is responsible for directly providing or arranging all primary, inpatient hospital and long-term care services required by a PACE member. Most participants are dually eligible for Medicare and Medicaid, with a small number in only one or the other.
Community-Based Long-Term Care
- A category of services covered under Medicaid consisting of:
- Personal Care Services (excluding those who need only housekeeping)
- Consumer-Directed Personal Assistance Services
- Certified Home Health Agency
- Adult Day Health Care (but not social-model adult day care)
- Private Duty Nursing
- Long-Term Home Health Care Program (Lombardi waiver)
An individual must require at least one of those services for at least 120 days per calendar year in order to be eligible to enroll in MLTC. Furthermore, a dual eligible age 21+ who requires at least one of those services for at least 120 days per calendar year is required
to enroll in MLTC.
Long-Term Care - health-related services provided to a person with disabilities that assist that person in completing activities of daily living and/or maintaining maximum functioning. Includes both community-based long-term care (see CBLTC) and facility-based (e.g., nursing home, assisted living residence).
Personal Care Aide
- aka "home attendant." A semi-skilled paraprofessional certified under NY law to provide assistance with certain specified activities of daily living for people with disabilities. See 18 NYCRR § 505.14; Personal Care Aide Scope of Practice at http://www.wnylc.com/health/download/46/
Consumer Directed Personal Assistance Program - a type of Medicaid-covered Community-Based Long-Term Care in which the consumer can select, train, supervise, and schedule his/her own personal assistants, who are not required to be certified as PCA/HHAs and who are exempt from the restrictions of the Nurse Practice Act (i.e., they may administer medication and perform other skilled tasks, unlike PCA/HHAs). 18 NYCRR § 505.28.
Adult Day Health Care (aka "medical model" adult day care) - Medically-supervised services for individuals with physical or mental impairment. Potentially includes nursing, transportation, leisure activities, physical therapy, speech pathology, nutrition assessment, occupational therapy, medical social services, psychosocial assessment, rehabilitation and socialization, nursing evaluation and treatment, coordination of referrals for outpatient health, and dental services. It is covered by both fee-for-service Medicaid and Managed Long-Term Care (all flavors).
Social Adult Day Care (aka "social model") - SADC is a structured program designed to support the physical, mental, social and emotional functioning of frail adults or those with a cognitive disorder. Unlike Adult Day Health Care ("medical model"), which is provided in a healthcare facility supervised by doctors, SADC is provided in non-medical settings. It is not covered by fee-for-service Medicaid, but is available under the Lombardi and NHTD waivers, and under Managed Long-Term Care (all flavors).
Private-Duty Nursing - Clients with continuous skilled nursing needs may need a Licensed Practical Nurse (LPN) or Registered Nurse (RN) for up to 24-hours a day. Intravenous or parenteral nutrition, suctioning of tracheostomies, direct administration of medications (putting a pill directly in the client’s mouth), and operating a ventilator are examples of tasks that PCA/HHAs may not perform. PDN is covered (subject to prior approval) by fee-for-service Medicaid and by all types of Medicaid Managed Care plans (MMC, MLTC, etc.) 18 NYCRR § 505.8.
Nursing Home Transition and Diversion Waiver - a Medicaid Home and Community Based Services waiver program in New York which is designed to help transition nursing home residents back to the community, and to divert nursing home-eligible individuals from institutional placement, by providing a comprehensive package of long-term care services in the community. NY Soc. Serv. L. § 366(6-a).