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As described in this article, most adults in NYS who have Medicaid and Medicare, who need Medicaid personal care or CDPAP services or long-term CHHA or adult day care services, must select and enroll in a managed long term care plan, or a PACE or Medicaid Advantage Plus plan. Starting in May 2022 those not already receiving personal care or CDPAP through their local Dept. of Social Services (DSS) must be assessed through the NY Independent Assessor - see more here. For those who are receiving home care through their Local DSS, such as for Immediate Need, if they don't select one within 60 days of receiving an enrollment letter from New York Medicaid Choice, they will be assigned to a "partially capitated" managed long term care (MLTC) plan. (See more information on the enrollment process) The information they will receive -- Links to the information consumers are receiving from New York Medicaid Choice is in this article, including the following:
If the consumer does not select a plan, they are randonly assigned to a plan. Even if New York Medicaid Choice helps them pick a plan, we understand that the sole criterion NY Medicaid Choice will use in plan selection is the plan network of providers -- this company will have access to an internal database showing all of the networks of providers in each plan, so that it can recommend a plan that contracts with the providers of the client's choice. Here is other information that may be helpful in selecting a plan. NYLAG MLTC Data Transparency ProjectClick on this link to compare extensive data about different MLTC plans in different regions, including how many hours of personal care or CDPAP plans authorize. Read NYLAG's Report about what data is available to compare plans, and recommending more transparency from the State. NYS Dep't of Health MLTC Consumer Guides and ReportsAll MLTC plans are required to report certain quality data to the State. The State posts reports each year at this link. including some results of customer satisfaction surveys conducted by the Dep't of Health. These data for have been summarized on the DOH website, and may help consumers comparing different plans: Please note that consumer advocate have criticized the State's reports for lacking important information that is necessary for consumers to make an informed choice about plans. See New York’s 2012 Managed Long Term Care Report: An Incomplete Picture (April 2013) -- The Coalition to Protect the Rights of New York’s Dually Eligible issued this "Incomplete Picture" Report as a critique of the NYS Dept. of Health's 2012 Managed Long Term Care Report, issued in December 2012. The State's Report does not provide the full spectrum of information that beneficiaries need to make informed health care choices -- For example, The 2012 Report presents the most favorable findings of consumer surveys, but fails to mention less positive but important findings from IPRO’s report, including the fact that higher need respondents in poorer health were significantly more likely to raise concerns about services than those in good health. The Report fails to include any meaningful utilization data, showing the amount of and type of services provided by MLTC plans or the medical-loss ratios of the various plans. The Report fails to comply with the Public Health Law that requires the report to present information in a way that allows beneficiaries to make meaningful comparison between plans. Inadequate quality data is reported as well. ASK PLAN TO COME TO HOME, ASSESS NEEDS & DESCRIBE PROPOSED CARE PLAN BEFORE ENROLLING.The State's Q & A issued Aug. 21, 2012 states: Q39. How do new Medicaid applicants enroll into MLTC? Can they be assessed by multiple plans prior to enrolling or must they enroll in order to get assessed for services? A39. Consumers new to service must be assessed prior to enrollment. Consumers may contact multiple plans and request assessment, however, services will not be provided until they are enrolled in a plan. Q44. In mandatory enrollment zip codes, if a consumer contacts a plan to see options during the 60 day period, if a plan conducts a visit, is the consumer entitled to a written plan of care before the enrollment? A44. The plan is responsible for issuing a written plan of care. Information about plansADA - Americans With DIsabilities Act Compliance by MLTC PlansAn analysis completed by the Center for Independence of the Disabled NY (CIDNY) found MLTC Plans out of compliance with ADA requirements. See Letter to Mark Kissinger, Dep. Commissioner NYS DOH, dated Oct. 5, 2012, from Susan Dooha, Exec. Director, CIDNY, posted at http://tinyurl.com/CIDNY-MLTC-ADA, referencing Chart Comparing MLTC ADA Plan Compliance, posted at http://tinyurl.com/CIDNY-MLTC-ADA-chart-xls. Continuity of Care Requirements - Requires Plan to Contract with Former Providers for Short PeriodOne important factor in choosing a plan is whether you can keep your aide that worked with you when CASA/DSS or a CHHA authorized your care before you enrolled in the MLTC plan? Statewide, the new MLTC plan is required to contract with all home attendant/personal care agencies, certified home health agencies, Lombardi programs, and other care providers that previously had contracts with the local Medicaid program, at least through March 1, 2014. See Final Continuity of Care Policy for Managed Long Term Care. This policy is intended for them to be able to keep the same aide they had in the CASA program. If they learn that the assigned MLTC plan does not contract with their current home attendant or home care vendor, they should ask the MLTC plan to do so so that they can keep their aide. Cite the above policy. If the MLTC plan refuses to allow the client to keep her aide, call the State Dept. of Health at 1-866-712-7197 (MLTC Complaint Line).
PLAN PROVIDER NETWORKSDespite requests from advocates, the State has not made publicly available any online listing of provider networks. While NY Medicaid Choice has access to some internal database, this is not being made public. The only public information is that posted on the plan's own websites or that the plan will mail you upon request. To help you identify networks, we have compiled information to the extent available as of July 2012. Is Provider Network Adequate?The MLTC Model Contract requires the MLTC plan to "...have a minimum of two (2 ) providers that are accepting new Enrollees in each county in its service area for each covered service in the benefit package unless the county has an insufficient number of providers licensed, certified or available in that county as determined by the Department. 4. Providers of covered services to which an Enrollee must travel must be geographically accessible for the enrolled population. Travel times must not exceed: a. Thirty (30) minutes from the Enrollee’s residence in metropolitan areas; b. Thirty (30) miles from the Enrollee’s residence in non-metropolitan areas. 5. If the Contractor is unable to provide necessary services through its contracted network for a particular Enrollee, the Contractor agrees to adequately and timely furnish these services outside of the Contractors’ network for as long as the Contractor is unable to provide them within the network DOH Model MLTC Contract, Article VII Part D (p. 46) Look at whether your other providers are in the plan's network. For example -- Nursing Homes in Network and QUALITY of care in Nursing homesWHAT NURSING HOMES ARE IN MY PLAN'S NETWORK? -NYLAG is beginning to compile charts to compare networks of plans from the directory information listed below. The first type of provider network compiled is for NURSING HOMES covered by each plan.
Q42. As discussed on the MLTC weekly call, can you please confirm that the following assertions are true, and if not, please clarify the policy on the following: (1) MLTC plans must pay the member’s Medicare coinsurance for skilled in-patient rehabilitation services provided in an SNF, regardless of whether the facility is in the MLTC plan’s nursing home network. A42. Yes, Managed Long Term Care plans must pay the member’s Medicare coinsurance for nursing facilities. NOTE - However, after the Medicare coverage ends, MLTC plan may decline to pay for nursing home care unless member transfers to an in-network nursing home. The MLTC plan must cover the cost of care pending a reasonable period to transfer. Q&A dated Aug. 16, 2012 Q&A No. 49.
DentistsIn addition to a plan’s network of dental providers, MLTC recipients as well as mainstream managed care members have the right to access dental services at Academic Dental Center clinics licensed under article 28 of the NY Public Health Law. N.Y. Pub. Health Law § 4403-f(7)(b)(vii)(D) (MLTC statute expressly incorporating Medicaid managed care requirements at N.Y. Soc. Serv. § 364-j(4)(a)(iii)(D)). There are five dental centers in New York State that meet these criteria. They are:
Under the Model MLTC contract, dental services at these clinics may be accessed without prior approval and without regard to network participation. Plan must reimburse at reimburse the clinic for covered dental services provided to enrollees at approved Medicaid clinic rates. See Article VII(H)(1) at page 48 of contract. See also MAP Model Contract, at § 22.12(a); PACE Model Contract, at Art. V(L)(c)(sic). See N.Y. Dep’t of Health, Question and Answer Sheet: Transition of Dental and Orthodontia Coverage from Fee for Service to Medicaid Managed Care OptometryLike dental care, optometry services provided by Article 28 clinics affiliated with the College of Optometry of the State University Eye Center - also offers Homebound visits MLTC Plan Provider Networks - Where to Find Info (based on info provided by plans and State DOH January 2013)
MEDICAID ADVANTAGE PLUS
PACE
This article was authored by the Evelyn Frank Legal Resources Program of New York Legal Assistance Group.
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