All of the policies and procedures described in this article may be changing. as the result of the NYS Budget enacted in April 2018. This budget reverses the MLTC expansion to include nursing home care that is described in this article. Once implemented, adults with Medicare and Medicaid who are permanently placed in nursing homes for more than 3 months will no longer be required to enroll in MLTC plans. Those who are already members of MLTC plans when they enter a nursing home will eventually be disenrolled from the MLTC plan if they remain in the nursing home. This change is not yet implemented as of AUGUST 12, 2019, pending approval by CMS. So this article remains current. Stay tuned for changes. See more on this and other 2018 MLTC changes here.
Since February 1, 2015, there has been a new requirement for nursing home residents in New York City who became "permanent" residents after that date to enroll in Managed Long Term care (MLTC) and "mainstream" Medicaid Managed Care plans, which will now pay for and manage the nursing home care. CMS approved this expansion of MLTC and mainstream Medicaid managed care by letter of Dec. 31, 2014. "Permanent" status does not begin until after Institutional Medicaid eligibility has been approved, following the 5-year lookback. Thus enrolling in a managed care or MLTC plan is not required for initial admission to a nursing home.
The requirement started in NYC in February 2015, and the rest of the state was phased in by October 2015.
Since Jan. 22, 2015 and continuing through September 2015, NYS DOH has conducted a series of webinars on this transition and has issued a series of policy papers and FAQs: All are posted on the MRT 1458 website - scroll to the bottom to:
State DOH Administrative Directive 15ADM-01 - Transition of Long Term Nursing Home Benefit into Medicaid Managed Care (April 1, 2015) - to local county Medicaid programs to explain the new procedures for Medicaid for nursing home care: PDF Attachment 1
NEW YORK CITY PROCEDURES and FORMS -
Adults age 21+ becoming permanent nursing home residents in NYC after February 1, 2015 (estimated) will be required to enroll in managed care plans starting in Feb. 2015 in NYC, in Long Island and Westchester in April 2015. Upstate mandatory enrollment will begin in July 2015 on a rolling basis. The State's presentations above reviewed timelines, network requirements, reimbursement policies and other key areas of concern.
The type of managed care plan in which the individual must enroll depends on whether or not they receive Medicare.
Current nursing home residents are "grandfathered in" - do not have to enroll in managed care plans. Anyone already in a nursing home before Feb. 1, 2015 (and before Oct. 2015 outside of the NYC metro area) will not have to enroll in a managed care plan, and will continue to have Medicaid pay for their nursing home care on a "fee for service" basis. The State says that no one already in a nursing home should have to change nursing homes because the nursing home is not in the plan's network.
If they are required to enroll in an MLTC plan or, if they are not on Medicare, in a "mainstream" managed care plan, they will enroll in a plan that affiliates and pays for their current nursing home.
This requirement will apply only people who, after Feb. 1, 2015, are approved for permanent nursing home placement and institutional Medicaid (after the 60-month lookback review is completed). It will not require enrollment into an MLTC or mainstream plan upon admission to a nursing home.. it will not be required until later, after they apply for and are accepted for institutional Medicaid.
Those who are already enrolled in an MLTC or mainstream Medicaid managed care plan in the community, who come to need long-term nursing home placement after Feb. 1, 2015 (if in NYC, or April 1, 2015 in Long Island and Westchester) or in other areas when they become mandatory, will no longer be disenrolled from the plan when they need nursing home care. They will need to choose a nursing home within the plan's network (or may sometimes change plans) and the plan will still manage their care in the nursing home.
MLTC members who only need short-term rehabilitation care, however, may go to any rehab facility of their choice, and are not restricted to facilities in their MLTC plan's network. The MLTC plan must pay the Medicare coinsurance for the skilled nursing facility (rehab) stay. SEE DOH Q&A Aug. 16, 2012 - Question 42 on page 7. However, once the Medicare-covered stay is over, they must switch to an MLTC plan that includes their preferred nursing home in its network. If the Medicare stay is less than 29 days, they may get additional days up to a total of 29 days, including Medicare-covered days, under the community Medicaid short-term rehabilitation benefit. For that care no 5-year lookback application is needed.
Mainstream members who need 29 days or less of nursing home coverage are entitled to Medicaid short-term rehab benefits, which covers up to 29 consecutive days under community Medicaid, without needing to do the 5-year lookback Medicaid application.
People who were NOT enrolled in an MLTC plan or mainstream plan who come to need nursing home care after Feb. 1st, 2015 (in NYC - rest of state timeline is here) may enter any nursing home of their choice. They do not have to join an MLTC or managed care plan until after they are admitted to the home, apply for and are accepted for institutional Medicaid (which includes the lookback period that screens for transfers of assets).
Phase-In Schedule - The original date was March 1, 2014, which was delayed several times. New schedule here. Concerns raised by NYLAG and other consumer advocates by letter of March 14, 2014, were part of the reason for the delay, with CMS requesting further protections in the state implementation plan. Now, with the ICAN Ombudsprogram and the Conflict-Free Evaluation and Enrollment Center up and running, CMS has approved this expansion of managed care. See more about this in this article in September 2014 news. People who first become permanent Nursing Home residents after the dates below, meaning their eligibility has been determined after a 60-month Lookback application, must enroll in either a Medicaid Managed Care or d Managed Long Term care plan, which one depends on whether they have Medicare.
Advocacy organizations including Medicaid Matters NY, the Coalition to Protect the Rights of New York's Dual Eligibles (CPRNYDE) and other organizations have participated in workgroups, voicing consumer concerns about many aspects of this expansion of managed care.
10/22/2015 - Coalition to Protect the Rights of NY Dual Eligibles - Issues and Concerns on Carve-in of Nursing Home Benefit into Managed Care and MLTC
On March 14, 2014, NYLAG and six other consumer advocacy organizations in NYS sent a letter to the federal Medicaid agency, CMS and to the State Dept. of Health asking them to slow down the expansion of Medicaid managed care to include all new nursing home residents who become permanently placed in nursing homes after April 1, 2014. The advocates pointed out numerous systems and procedures that are not ready for such a massive change, and the lack of education about these changes for hospital social workers, medical professionals and myriad other professionals who work with seniors and people with disabilities. Advocates are concerned that without adequate preparation, the rights of vulnerable New Yorkers will be violated -- including the right under the Americans with Disabilities Act to Medicaid services that enable them to live in the "most integrated setting" -- which is at home in the community rather than in an institution. Download the letter here.
May 2013, consumer advocates raised concerns about nursing home enrollment in managed care in the "FIDA" proposal to manage care for dual eligibles,