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MLTC Updates - 2012 - 2013

25 Nov, 2013

NYLAG has been publishing a running news article with updates about the roll-out of Managed Long Term care.  The most current news is posted here http://www.wnylc.com/health/news/41/. - includes updates since Jan. 1, 2014.

Earlier postings from 2013 are in this article

More information about Managed Long Term Care is posted here

New in December 2013

  • First letters sent out for mandatory enrollment in FOUR Upstate Counties -- Albany, Erie, Onondoga and Monroe.   CMS approved extension of mandatory enrollment to cover the larger metropolitan areas of Syracuse, Buffalo, Rochester, and Albany.  On some yet unspecified date on or after December 1st, the "front door" will close in these counties for Medicaid community-based long term care services. 
    • FOR NEW APPLICANTS -- This means that a Medicaid recipieint who wants to apply for Medicaid personal care, CDPAP, medical adult day care, or private duty nursing services will have to enroll in a Managed Long Term Care, PACE, or Medicaid Advantage Plus (MAP) plan to receive these services, and can no longer apply to the local Medicaid program for them. 
  • See more about the different types of plans, enrollment procedures and consumer protections in this article
  • See Tools for selecting an MLTC plan
  • See grievance and appeal rights  and appeal contacts

New in November 2013

New in September -October 2013

Orange and Rockland Counties - Start Mandatory MLTC Enrollment

CMS approved mandatory enrollment in MLTC plans to begin in Orange and Rockland counties.  The "front door" to apply to the local Medicaid program is closed as of Sept. 23, 2013 for personal care, Consumer-Directed Personal Assistance Program and adult day health care services.   Individuals already receiving any of those services in these counties, as well as those receiving private duty nursing services, are beginning to receive the so-called "announcement" letter from the State Dept. of Health that explains the changes, but does NOT require the individual to join a plan. See also Spanish version -- Aviso importante de Medicaid  

About 30 days after receiving that letter, the individual will then receive a letter from NY Medicaid Choice --Form Letter to Personal Care/Home Attendant recipients  -- the enrollment broker under contract with the State Dept. of Health, requiring them to join an MLTC plan (or PACE or Medicaid Advantage Plus) within 60 days, or they will be randomly assigned to a plan.  The letter will include  a Guide to MLTC, along with lists of plans by geographic area, which can be downloaded from NY Medicaid Choice website. See http://nymedicaidchoice.com/program-materials. 

Spousal Impoverishment Protections Extended to Managed Long Term Care Programs

On Sept. 24, 2013, New York State announced that "spousal impoverishment protections" are available to married participants in all Managed Long Term Care (MLTC) plans, including PACE and Medicaid Advantage Plus plans.  See NYS DOH GIS 13 MA/018 Spousal Impoverishment and Transfer of Assets Rules for Certain Individuals Enrolled in Managed Long Term Care.  These protections have long been a hallmark benefit to married spouses participating in the Lombardi or Long-Term Home Health Care Program (LTHHCP). The Lombardi program is gradually being phased out.  Current Lombardi program participants in the mandatory MLTC counties are being required to enroll in an MLTC plan if they are dual eligibles.  Many married Lombardi participants in the mandatory counties faced tremendous financial hardship if the spousal impoverishment protections did not continue once they transitioned to MLTC.  Read more about it here

114,800 people  Enrolled in MLTC as of September 2013 --

New in August 2013


On August 12, 2013 State DOH directed MLTC plans to begin disenrolling people who need only "Housekeeping" services, also known as Level I Personal Care services, as described in 18 NYCRR 505.14(a).   Though as Medicaid personal care recipients they were originally required to enroll in MLTC plans, DOH has now decided they do not meet the criteria for MLTC and should remain in the fee-for-service Housekeeping service administered by HRA and other local DSS programs.  New people needing these services may resume applying at their local CASA/DSS.   As a result of budget cuts in 2011, these services are now limited to 8 hours per week.   MLTC plans may of course continue to provide housekeeping services to people who also need "Level II" personal care - that is, assistance with activities of daily living suchas grooming, bathing, mobility, transfer, dressing, etc.  The same personal care aides assist with all of these activities.

New MLTC Plans Approved and Begin Enrollment - Plans Expand to Additional Counties

In July 2013, there are now 23 partial-capitation MLTC plans in NYC alone, plus 10 Medicaid Advantage Plus plans and 2 PACE plans.  Many upstate counties that previously had NO MLTC,PACE, Or MAP Plan now have one.   All counties next slated for mandatory enrollment later in 2013 have at least 2 plans..  (Rockland, Orange were supposed to begin mandatory enrollment in June 2013 but it has been delayed, and  Albany, Erie, Onondaga and Monroe are slated for later in 2013).  Total of 104,872 people in MLTC plans as of July 2013, of which 95,643 are in NYC.

This chart shows the July 2013 enrollment figures by county and by plan for all three types of plans.  At page 4 of the document is a chart showing enrollment in NYC.  At page 5 of the same document is a chart showing monthly total enrollment comparing upstate, NYC and statewide for MLTC and PACE plans.  The monthly enrollment data is compiled from DOH stats posted at http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/. 

NYC MLTC-MAP-PACE Plan List by Company - NYC July 2013.pdf --showing which different MLTC/MAP/PACE plans are offered by the company as of July 2013 - New York City only

New in June 2013

Hospice & MLTC -- June 25, 2013 State Directive MLTC Policy 13.18: MLTC Guidance on Hospice Coverage 

MLTC members no longer have to disenroll from MLTC plan when they need to enroll in hospice care.  MLTC should "wrap around" and supplement the hospice care, which is provided separately by a hospice.  BUT - anyone receiving hospice services is still excluded from first enrolling in an MLTC plan.  If they are already in MLTC, they don't have to disenroll from the MLTC plan in order to get hospice care.

NEW MLTC PLANS -- New York Times -- State Rewards Home Care Firms Once Rebuked (Nina Bernstein, June 24, 2013) - investigating award of MLTC contracts to two companies that sponsor Certified Home Health Agencies that have a history of Medicaid fraud. 

June 26, 2013 -- State Postpones for One Month New Requirements  that Plans Disenroll People who Need Only "Housekeeping" services, while Procedures are Developed 

Since April 2013, the State. Dept. of Health has  issued several policy bulletins that clamp down on who is eligible for MLTC. 

First, in April and May, the State said that people who need only Social Adult Day Care (SADC) and not any home care or other long-term care services are not eligible for MLTC.  SEe MLTC Policy 13.11: Social Day Care Services Q&A (PDF 119KB) Letter from State Medicaid Director Helgerson to MLTC Plans on SADC.  This was in reaction to the influx of people into MLTC recruited by the pop-up SADC centers. 

Next, earlier in June, the State said that people who need only "Housekeeping" -- formally known as Personal Care Level I services  (18 NYCRR 505.14(a)), are not eligible for MLTC and must be disenrolled by the plans.  When given alone, Level I services are limited to 8 hours/week.  The State's instructions to plans were given in a series of 3 directives, all posted on MRT 90: Mandatory Enrollment Managed Long Term Care

  1. MLTC Policy 13.14: Questions Regarding MLTC Eligibility 
  2. MLTC Policy 13.15: Refining the Definition of CBLTC Services (
  3. MLTC Policy 13.16: Questions and Answers Further Clarifying the Definition of CBLTC Services 

NYLAG'S Evelyn Frank Legal Resources Program sent an e-mail to State DOH on June 25th alerting them to serious problems with mass disenrollment of people who allegedly need only Housekeeping.  The State apparently expected the plans to refer these individuals back to their local DSS/CASA office which was to reinstate the Housekeeping services that were previously cut off when the individual was required to enroll in an MLTC plan.  But -- there are no clear established procedures to make this transition happen, and it was very likely to disrupt these important services.   Moreover, the State said the members could not appeal the plans' decision that the member was not eligible for MLTC because she solely needs Housekeeping ad not other MLTC services.  A complete copy of NYLAG's e-mail to the State is copied below. 

As a result of NYLAG's advocacy, the State agreed to suspend these disenrollments for at least a month while procedures are developed.  An e-blast was was sent by State DOH to all MLTC plans today, June 26, 2013, postponing these policies for one month or until a date to be announced, and requiring plans to halt any disenrollments already initiated.  Here is the language of the State's e-blast sent June 26th:

The purpose of this email  is to advise MLTC plans that the Department of Health, in order to assure coordination of activities with local social services districts related to refining the definition of  community based long term care services to exclude individuals requiring discrete Level I housekeeping services,  has delayed the implementation of  MLTC Policy 13.15: Refining The Definition of CBLTC Services  for one month.    MLTC plans who have initiated assessment and disenrollment  actions to implement  MLTC Policy 13.15 should immediately retract any actions relating to disenrollment.    The Department will reissue, in the near future,  a  policy document which will provide additional guidance and include a date when implementation should occur.

If you have clients threatened with disenrollment that is based on this policy:

  • call the State Dept of Health MLTC Complaint Line 1-866-712-7197 
  • advocate with the Plan representative and go up the chain of command with the plan informally, using this e-mail
  • Request an internal appeal with the plan - see contacts at Grievance and Appeal Contacts for Managed Long Term Care Plans
  • please cc  us with details at eflrp@nylag.org so that we can let DOH know of problems with compliance.     

Adult Day Care -NYC Council Bill Would Crack Down on Proliferation of Adult Day Care Centers --By NINA BERNSTEIN (June 6, 2013 - NY Times) 

LOMBARDI program  --will be closed to new enrollment for dual eligibles in mandatory counties on June 17th.  The program was closed to new members with Medicaid only on May 15th.   Lombardi participants living in counties that do not yet have mandatory MLTC (all counties outside NYC, Long Island and Westchester)  may still stay in the Lombardi program.

Transition rights --  In mandatory counties, the MLTC plan must continue providing the entire plan of care from the Lombardi program for 90 days, using the same providers, and pay the Lombardi program for those services -- including those that the Lombardi program contracted out.   This is under MLTC Policy 13.13: Continuity of Care and Payment Requirements of MLTC Plans to LTHHCP Agencies Providing Care During the 90 Day Transition Period  - May 30, 2013

New in May 2013

Federal Govt. Issues Guidance to States on Managed Care for Long Term Services and Supports


Additional resources for MLTSS programs are available in a CMS Informational Bulletin released on May 21, 2013

UPDATE on LOMBARDI program - transition to MLTC

See Approved Long Term Home Health Care Program (LTHHCP) 1915 (c) Medicaid Waiver Amendment   - undated NYS DOH Explanation of which LTHHCP (LOMBARDI) participants must transfer to managed care or managed long term care plans.  In summary -

    • who are already in a Lombardi Program - will receive letters beginning April 1, 2013 that they must select and enroll in a Mainstream Medicaid managed care plan -- OR apply to a different waiver (TBI or Nursing HOme Transition or Diversion Waiver (NHTDW)  or OPWDD waiver, or for children under 18 - Care at Home waiver).  If they don't, they will be assigned to a Medicaid managed care plan.  Once enrolled, that managed care plan will take over all of the Lombardi services.
    • new enrollment  in Lombardi for people without Medicare closed on May 15, 2013.   New applicants after May 15, 2013  may obtain Medicaid home care through:
      • a TBI, NHTDW, or OPWDD waiver,
      • Care at Home waiver (if under age 18),  
      • a Medicaid managed care plan,
      • if they are not yet in a Medicaid managed care plan, they may obtain personal care services through their local Dept. of Social Services.  
      • Alternately, if they are over age 18 and would otherwise qualify for nursing home care, they may enroll in a MLTC plan for long-term care and use regular Medicaid for other Mediciad services.  
  • PEOPLE WITH MEDICARE (Dual Eligibles)
    • who are already in a Lombardi program -
      • If they live in NYC, Nassau, Suffolk or Westchester counties, they are now receiving or will soon receive letters that they have 60 days to select a Managed Long Term Care (MLTC) plan.. or they will be assigned to one.  They have the option of enrolling in the TBI, NHTDW, or OPWDD waivers if they are eligible instead of in MLTC.
      • If they live outside NYC, Nassau, Suffolk, or Westchester counties - they can remain in the Lombardi program for the time being but will eventually be required to transfer to an MLTC plan or one of the other waivers.
    • Who now want to enroll in Lombardi --
      •  If they live in NYC, Nassau, Suffolk or Westchester counties - new enrollment in Lombardi closes on June 17th.    Must enroll in MLTC, MAP or PACE, or one of the other waivers - TBI, NHTDW or OPWDD if home care is needed.  If under 18, Care at Home waiver is an option. 
      • Outside these counties - unclear when "the front door" to Lombardi will close.  

See more on Lombardi and MLTC below under APRIL 2013 NEWS .

DOH ISSUES 2 DIRECTIVES TO MLTC Plans (1) Extending Transition Period from 60 to 90 Days, in which Plans must Continue the Same Home Care or CHHA Services that New Members Received Before Enrolling in MLTC  and (2) on Social Adult Day Care Requirements

Transition Period Extension & Barriers to Enrollment --

On May 8, 2013, the State Dept. of Health released  MLTC Policy 13.10: Communication with Recipients Seeking Enrollment and Continuity of Care which attempts to address problems raised by consumer advocates of plans discouraging prospective members from enrolling by telling them that the plan "doesn't provide 24-hour care,"  that  the family must supplement the care privately, etc.    These problems were raised by NYLAG, Empire Justice Center, CIDNY, the Legal Aid Society, and other consumer advocates at a meeting with Mr. Helgerson on April 30, 2013, as reported by the New York Times on May 1st.

Policy 13.10 also extends the initial transition period, during which the plan may not reduce services previously received from CASA/DSS/CHHA.  This period is now 90 days, extended from the former 60 days.

Social Adult Day Care Update --

[the rest of this article and earlier posts were accidentally deleted]

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