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

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

"... 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.

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.  

  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.

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:

ALBANY 103
BROOME 266
ERIE 181
MONROE 534
ONEIDA 91
ONONDAGA 288
Total 1,463

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

August 2018 Update

July 2018 Update

March 27, 2018 update

February 28, 2018 update

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

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 - 

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

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

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29 Oct, 2018
MLTC UPDATE: Guildnet Closing Letters Sent to 7500+ Members - Learn Tips at NYLAG CLE on Nov. 14th, Nursing Home Changes in MLTC
http://www.wnylc.com/health/news/78/