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MLTC UPDATE: CDPAP Changes Enacted,in NYS Budget, Bill to Increase MLTC Transparency, March 1st - Transportation carved out of MLTC services
21 May, 2024
This is a running news article with updates on Managed Long Term Care in NYS.
FEBRUARY 2024 ALERT re CDPAP CUTS - see HERE
Please see archives for past articles:
KEY MLTC CONTACTS TO FILE COMPLAINTS -- And Websites
SKIP DOWN TO LATEST NEWS
NYIA WEBSITES https://nyia.com/en and https://www.health.ny.gov/health_care/medicaid/redesign/nyia/
May 2024
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The NYS Budget enacted sweeping changes in the CDPAP program. Read about what was passed in the final budget and what was rejected here. These changes affect all people receiving CDPAP, not only those in MLTC plans.
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NYLAG Supports the MLTC DATA TRANSPARENCY ACT - S9266 (May) / A10176 (Gonzalez-Rojas). The bill proposoing to replace MLTCs with a fee-for-service care coordinator did not pass in the recent NYS Budget. To shine a light on how MLTC plans spend $22 billion each year -- what services they provide, what is their track record on keeping people out of nursing homes -- data must be made public. Read NYLAG's Memorandum in Support of this bill here. This memo explains some of the terms used in the bill, which can be confusing. The bill requires that the State make public data the State already collects from plans, but which now can only be obtained by a Freedom of Information request. NYLAG obtained this data for 2018 and posted it in its MLTC Data Transparency Project. This bill would make this data regularly available for the public to compare plans and for state officials and consumers to hold them accountable.
March 2024
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MARCH 1st - Non-Emergency Medical Transportation will no longer be arranged and paid for by Managed Long Term Care plans. Providers and MLTC members must arrange transportation through Medical Answering Services (MAS). Read more in this article.
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Capital Press Room -- Listen to Bryan O'Malley and Blaise Bryant of the NYS Association of Independent Living talk about the proposed CDPAP cuts described below.
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Independent Report Supporting Repeal of MLTC Program - Paul Francis, who served under four New York Governors in roles including Budget Director and Director of Agency Redesign and later the Deputy Secretary for Health and Human Services under Gov. Cuomo when the Managed Long Term Care program launched in 2011, now heads a think tank that issued a critical review of MLTC, agreeing that the Home Care Savings & Reinvestment Act (S8700/A8470)(Rivera/Paulin) replacing the MLTC program with a new system will save money and should be strongly considered. Read the report here. This report was covered in Crain's Health Pulse on March 5, 2024 (unfortunately behind a paywall) - see Home care Overhaul is a Serious Proposal to cut Medicaid Spending, Independent Report Finds.
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Devastating Proposed CDPAP CUTS --
The Governor's proposed Budget for FY 2024-25 proposes unprecedented cuts to the Consumer-Directed Personal Assistance Program (CDPAP).
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First, CDPAP aides "called "personal assistants" in the downstate area would see their hourly wages cut drastically because the "prevailing wage" increase would be taken away in New York City, Long Island, and Westchester.
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Next, in the 30-Day Amendments to the budget, the Governor proposed to limit CDPAP only to people who can "direct" their own care. This would disqualify all people who have Alzheimer's disease or other types of dementia or cognitive impairments, those with Traumatic Brain Injuries and Intellectual and Developmental Disabilities. Children under 18 would also be disqualified from CDPAP - even though those with severe disabilities rely on this service to remain at home and avoid institutionalization.
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Organizations can SIGN ON here to support a joint letter protesting these drastic cuts. Please sign on by Thursday Feb. 29th at 3 PM.
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To learn more - read NYLAG's Statement Opposing the CDPAP Cuts and read the Legislative Agenda of Consumer Directed Action of NY (CDANY).
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Also, read NYLAG's FY 2024-25 Budget Testimony here.
- NYLAG Supports the Home Care Savings & Reinvestment Act (S8700/A8470)(Rivera/Paulin).
This bill would repeal the Managed Long Term Care program and replace it with a Managed Fee for Service program. Read NYLAG's memorandum in support of this bill. NYLAG's support is based on 12 years of advocacy, both on behalf of individual consumers and in class action litigation, and NYLAG's study of data in its MLTC Data Transparency Project and Report,
Watch this powerful 3-minute film called #CareNOTProfits about the bill proposing to replace MLTC. Learn more at https://www.nycaringmajority.org/carenotprofits.
November 2023
October 2023
- NY Independent Assessor Program (NYIAP) To Expand in 2024 to Include Reassessments - On Oct. 20, 2023, Consumer Advocates Called on NYS DOH to slow down expansion of NYIAP to conduct REASSESSMENTS for home care - for MLTC, managed care plans, and Local districts - to be phased in starting Jan. 1, 2024 through 2024.
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DOH announced the expansion of NYIAP on Oct. 2, 2023 - see the announcement and roll-out schedule in this article. This means NYIA will take over conducting BOTH routine annual reassessments AND requests for increases mid-year (called "non-routine" assessments) for members of MLTC plans, mainstream Medicaid managed care plans, and those receiving personal care or CDPAP through their local county or HRA. The NYIAP take- over will start up state, then expand to Long Island and NYC throughout 2024.
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Medicaid Matters NY, a statewide coalition of advocates for NYS Medicaid consumers, sent this letter to the NYS Medicaid Director on Oct. 10, 2023 asking them to slow down this expansion of NYIAP. Advocates question whether NYIA has enough nurses and other staff to conduct thousands more assessments each month -- without causing harmful delays. Delays will especially be harmful for those seeking an "expedited" increase in home care hours because of a sudden change in condition, including those who cannot leave a hospital or rehab facility without more home care.
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View recording of NYLAG WEBINAR on NYIA February 8, 2023 -- View recording here and download Powerpoint HERE.
- See more about NYIAP here
July 2023
- NYLAG filed these comments to the federal CMS Medicaid agency's proposal to improve standards for accessing Home and Community-Based Services (HCBS) Provisions. See CMS summary of its proposal here and its press release here about the series of reforms proposed including these on HCBS. For a national perspective, see comments of the National Health Law Program here.
June 2023
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August 1, 2023 - Extended MLTC will be closing and will become part of Hamaspik Choice MLTC. Notices sent to members in early June to select a different plan by July 31st or they will be enrolled in Hamaspik. See more here.
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MLTC members, like all Medicaid recipients, are beginning to receive annual Medicaid "renewals," which had been suspended for three years during COVID. Read about the "unwinding" of the Public Health Emergency here, during which Medicaid could not be cut off for any consumer.
May 2023
- View NYLAG's VALERIE BOGART slide deck and presentation at the annual Elder Law Forum in Albany NYS held on May, 2023 about the Unwinding of the Public Health Emergency, the 2023 Expansion of Medicaid Eligibility, and the NY Independent Assessor. Slide Deck at this link (pp. 77 - 127) and view presentation at this link. See all of presentations at the all-day forum at this link.
February 2023
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Recording available for NYLAG WEBINAR: Update on NYIA February 8, 2023 -View recording here and download Powerpoint HERE.
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Recording available for presentation on the NYLAG MLTC Data Transparency Project - view recording here
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Recent MLTC plan closings and mergers - see this article for updates about:
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Dec. 1, 2022 -- Integra, which had as 42,838 members in June 2022, mostly in NYC with some in Long Island and Westchester, was acquired by Anthem, which owns Empire-HealthPlus MLTC plan, with 4,726 members. Transition period ends Mar. 31, 2023. See more here.
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Oct. 1, 2022 - Agewell closed, which had 13,188 members in NYC, Long Island, and Westchester., acquired by Senior Whole Health, which has been owned and operated by Molina since Dec. 2020. Transition period ended Jan. 31, 2023. See more here
December, 2022
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REGISTER HERE for free NYLAG WEBINAR: Update on NYIA
February 8, 2023, 10 AM – 12 PM (CLE pending)
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NY Independent Assessor starts Dec. 1, 2022 for NEW applications submitted for Immediate Need. Please see information and new forms in the updated article on Immediate Need on this site.
November, 2022
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NY Independent Assessor - Despite advocates' concerns about huge delays and other problems with NYIA, the NYS Dept. of Health is proceeding to expand NYIA on December 1, 2022 to include Immediate Need applications made to the local Medicaid agencies, and expedited home care requests made to mainstream Medicaid managed care plans. Consumer groups together with plan associations jointly sent a letter in October 2022 to the Governor's office and Commissioner Mary Bassett asking to halt expansion of NYIA based on myriad problems. See October news here.
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Consumer Advocates Respond to the NYS Comptroller Report Finding MLTC - NYLAG joined Medicaid Matters NY and eighteen other advocacy groups to issue a statement responding to the August 2022 report by the Office of the NY State Comptroller, titled “Medicaid Program – Oversight of Managed Long-Term Care Member Eligibility.”
The consumer groups' statement applauds the Comptroller for highlighting data that illuminates the lack of oversight of MLTC plans by the NYS Department of Health (DOH), which are paid over $15 billion each year to provide services to this vulnerable population. The OSC Report identifies two broad findings:
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The more costly and concerning finding—that NYS paid $2.8 billion in premiums to MLTC plans that provided little or no services to their members—takes up only two pages of the report. The consumers' response calls for more robust DOH oversight of plans' failure to staff cases, to authorize sufficient home care services to prevent nursing home placement.
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Most of the report instead focuses on a finding that $701 million was paid to plans for consumers who were no longer eligible for MLTC -- members who had died or moved to an Assisted Living Program or to a county outside the plan's service area. The consumers' response expresses concern that the Department's efforts to disenroll people in these situations must be done carefully to avoid throwing out the baby with the bathwater -- mistakenly disenrolling people who still need and are eligible for home care.
Unfortunately, neither of these findings are surprising as NYLAG and other advocates have consistently sounded the alarm on a lack of needed oversight and monitoring of plans by the NYS Department of Health. The report urges OSC and the Department to focus more oversight on the failure of plans to provide the appropriate level of care.
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NY Independent Assessor - Oct. 27, 2022 --Consumer advocacy coalitions Medicaid Matters New York and the Coalition to Protect the Rights of New York’s Dual Eligibles joined with organizations that represent Managed Long Term Care plans and home care providers to send a joint letter to the Hochul administration to air concerns about and demand slowdown of implementation of the New York Independent Assessor. The letter can be downloaded here. It asks that the NYIA expansion to include Immediate Need requests and expedited mainstream Medicaid managed care requests, slated for Dec. 1, 2022, be halted until the myriad delays and problems with this new assessment system improve.
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September, 2022
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NYLAG has launched a new MLTC Data Transparency Project, using cost and operating reports filed by MLTC plans with the NYS Dept. of Health that are publicly available only through a Freedom of Information request. Visit the new webpage here, which features interactive visualizations allowing the user to view extensive data on how much each MLTC plan spends on home care vs. nursing home care and all other services and expenses, how many members receive various amounts of Medicaid personal care or CDPAP services in each plan, how services and costs vary between four regions of the State, and much more. See the announcement launching the project here and download NYLAG's full report with findings and recommendations here. Due to funding limitations and delays, the project uses 2017 and 2018 data, and calls on the state to post plan-specific data for later years publicly on an annual basis on its interactive Open Health Data site. See the full report for many more recommendations.
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LOOKBACK - The lookback for community-based long term care is officially delayed through March 31, 2024. See NYS DOH MRT website here.
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New York Independent Assessor update - New Form to Designate a Representative posted-
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At the request of consumer advocates including NYLAG and Medicaid Matters NY, the form for consumer to designate a representative was revised. See new form here posted on the NYIA website page on representatives. The site now says the signed form can be FAXed to (917) 228-8601 or mailed - address on website.
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This form is now separate from the Information-Sharing Consent form, which consumers have complained is difficult to use. See NYLAG fact sheet explaining how to complete and submit the consent form.
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On Aug. 30th, DOH delayed next phase of roll-out of NYIA from Oct. 1st to December 1, 2022 -- until then, applications to local DSS for Immediate Need personal care or CDPAP or expedited requests to a mainstream managed care plan for PCS and/or CDPAS do not go through NYIA. Directives posted on DOH NYIA webpage.
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The federal Public Health Emergency (PHE) was extended by U.S. HHS until Oct. 15, 2022, and will likely be extended for another 3 months because the Administration did not give the promised 60-day notice that the PHE will expire on Oct.15th. So it will be extended again on Oct. 15, 2022 until at least Jan 15, 2023. This means that the LOOKBACK and transfer penalties for new applicants for MLTC and other community-based care AND the eligibility change requiring new applicants to need physical help with 3 ADLs (2 if they have dementia) cannot start until at least April 1, 2023 (after the quarter in which the PHE ends). But these restrictions are likely to start later because of federal ARPA legislation. See more here.
July 2022
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In June 2022, DOH delayed implementation of NYIA -- but only for Immediate Need applicants to Local DSS and for Expedited requests for new authorizations for "mainstream" managed care rmembers for personal care and CDPAP. See DOH NYIA website with updates here All NYIA guidance is posted here.
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On May 16, 2022, NYIA started taking new requests for the new two-part assessment (nurse and then "clinical" medical assessment) -- both of which are now needed to enroll in MLTC or get new personal care or CDPAP services approved by the local DSS or a managed care plan (if reqested on a standard timeframe). See basics about NYIA assessments here and more on our advocacy webpage, including powerpoints, etc.
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NYIA has posted online a Consent Form allowing it to contact a consumer’s doctors and other medical providers when they assess eligibility for enrollment in a Managed Long Term Care (MLTC) plan, or eligibility to obtain Medicaid personal care or Consumer-Directed Personal Assistance (CDPAP) services through the local Medicaid office. The form states that it can also be used to designate an authorized representative for purposes of interacting with NYIA, though this part of the form is not clear.
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See top of this webpage for where to file complaints about delays in scheduling NYIA assessments and other NYIA problems.
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On May 3rd, 2022, NYLAG sent these questions and comments about the NYIA policy directives that are posted here.
April 15, 2022
NYS DOH has delayed implementation of the NYIA to be phased in as follows (latest announced by e-mail APRIL 15, 2022)(official NYIA website not yet updated - still shows May 1st start date):
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May 16th start date for MLTC enrollment and all new requests for Personal Care and CDPAP made to mainstream or HARP plans, or to local districts (DSS/HRA) on a standard timeframe
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July 1st start date for Immediate Need requests to DSS/HRA and all EXPEDITED PCS and CDPAP requests made to mainstream/HARP plans or to local districts.
See more here about NYIA and see NYLAG comments here
February 8, 2022 Update
- Independent Assessor Postponed to May 1, 2022 - DOH announced postponement of implementation to May 1, 2022 from March 1, 2022. Announcement is on the new Independent Assessor website, where presentations DOH gave to plans and local Medicaid offices beginning December 2021, are posted. NYLAG sent a set of questions about the information posted on DOH's website.
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View NYLAG webinar recorded 1/26/21 here and download PowerPoint here - note the 3/1/22 implementation date announced there has since changed to May 1, 2022, and webinar recorded before the above DOH website was made public, so does not include that information.
JAN. 11, 2022 update
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March 1, 2022 Start Date set by State DOH for the Independent Assessor, announced by DOH in a webinar conducted in late December 2021 solely for Plans and Local Districts, not for the public. However, as of Jan 11, 2022, no ADM or other guidance has been issued and DOH has acknowledged at a meeting iwth Medicaid Matters NY that NY Medicaid Choice lacks the capacity to conduct these assessments - in part due to nursing shortage aggravated by COVID.
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NYLAG and Medicaid Matters NY jointly sent this letter Dec. 15, 2022 to DOH with concerns about implementation, posted here with a Jan. 6, 2022 update.
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NYLAG posts Fact Sheet about the change in Transition Rights. that took effect Nov. 8, 2021.
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DOH posts guidance on some minor changes in the state Personal Care and CDPAP regulations, but not on the major new Independent Asssessor procedures. These changes apply to MLTC plans as well as mainstream plans and local Medicaid agencies. See 21 ADM-04 & MLTC Policy 21.06 (both 12/13/2021) - announce changes including:
- Reassessments now are annual not every 6 months
- CDPAP: only one FI per consumer; designated rep for non-self directing consumer must be present at all assessments, new agreement between consumer/rep and LDSS/plan
- M11q/physician’s order may be signed by Nurse practitioner, physician’s assistant, Osteopath – not just MD
- Tweaks permitted reasons for reductions in MLTC Policy 16.06:
- Tweaks policy on “safety monitoring” under NYS DOH GIS 03 MA/003 and MLTC Policy 16.07
November 3, 2021
- SOME HOME CARE CHANGES STARTING NOV. 8, 2021 - State DOH letter of Nov. 1, 2021 (PDF) clarifies which of the regulation changes published in the NYS Register on Sept. 8, 2021 and posted on the DOH website here will go into effect on Nov. 8, 2021.
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WHAT STARTS NOVEMBER 8, 2021 - The regulation cuts back on consumer rights after a "Transition Period." These changes will make it easier for a plan to reduce hours after a consumer is required to transition to a new MLTC plan. This could be after their old plan closes, or after they received Immediate Need services for 120 days, or after they first became enrolled in Medicare and had previously received home care from a "mainstream" Medicaid managed care plan. Read more about these transition rights and how they are changing along with advocacy tips, here. See NYLAG Fact Sheet about the change in Transition Rights.
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See other minor changes that start Nov. 8, 2021 in the DOH Nov. 1, 2021 letter.
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WHAT IS DELAYED: The new minimum of 3 ADLs (2 if have dementia) for home care and MLTC, and the new Independent Assessor procedures, both of which were enacted in the 2020 State budget will NOT be implemented yet, new date not yet announced. Read about the home care changes here . Some of these changes await CMS approval because of "maintenance of effort" requirements of the ARPA COVID relief legislation.
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State to Allow New Grounds for Involuntary Disenrollment - See here about growing list of grounds for involuntatry disenrollment that the State is allowing plans to initiate. While consumers have Transition Rights in the new plan they are assigned to after these disenrollments, the new regulation effective Nov. 8, 2021 described above threatens potential reductions in their hours after that transition period ends.
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CONFLICT FREE ASSESSMENTS HAVE LONG DELAYS - NY Medicaid Choice has been scheduling conflict free assessments (CFEEC) as much as 2 months after a request is made. These delays are in part due to a shortage of nurses who conduct these assessments. DOH told Medicaid Matters NY on Nov. 2nd that they expect improvements in these scheduling delays later in November.
ADVOCACY TIPS:
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Request for Immediate Need personal care or CDPAP services with HRA or your local DSS. See this fact sheet and article. But be prepared that in 120 days the consumer will be required to enroll in an MLTC plan, which must continue the same hours for 90 days. After that, the new regulation described above allows the MLTC plan to reduce services more easily than before.
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TIP - While the client receives Immediate Need services, file a HIPPA request for their entire file with the DSS - including all nurse and other assessments, plan of care, etc. This will be helpful if the MLTC plan tries to reduce services after the transition period.
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Phone in or email a Complaint with the DOH MLTC Complaint line to let them know about these delays.
October 25, 2021
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STATE REGULATIONS FINALIZED IMPLEMENTING 2020 changes in Home Care Eligibility and Procedures. The changes were published in the NYS Register on Sept. 8, 2021 and posted on the DOH website here. Though effective Nov. 8, 2021, State indicated some changes will be delayed.
NYLAG is disappointed that the final regulations are virtually same as the proposed state regulations to which NYLAG and other organizations submitted comments in March 2021. Most consumer advocate recommendations were rejected.
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TELEHEALTH NURSE ASSESSMENTS REINSTATED - On Sept. 30, 2021, NYS DOH reinstated Telehealth assessments for MLTC and other home care assessments, modifying July 26, 2021 - NYS Dept. of Health RESCINDS Some Home Care Rules - Requiring UAS In-Person, Requiring M11q/Physician Orders to be in Writing (not called in), and other changes
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Sept. 30, 2021 - DOH extends time for CDPAP personal assistants to have annual health assessment until Dec. 31, 2021 from Sept. 30, 2021. See here
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VACCINE MANDATE - DEADLINE WAS OCTOBER 7, 2021 for about 250,000 home care workers (except CDPAP) to have one vaccine - or not report to work on Oct. 8, 2021. The Gothamist reported on Oct. 16, 2021 the strain this has caused to some home care consumers, including a featured client of NYLAG who depends on round-the-clock private duty nursing. As reported on October 7th in the New York Times, tens of thousands of MLTC members and others receiving Medicaid home care services are at risk of having NO SERVICES if their aide(s) are not vaccinated. LIVES DEPEND ON THESE SERVICES! According to a survey by the trade group Home Care Association of NYS (HCANYS) - a very large number of aides and workers either refuse to be vaccinated or have not yet been vaccinated. The requirement was passed on August 26, 2021 as an emergency regulation. While increasing vaccination is absolutely vital to consumer safety and public health, a sweeping mandate must be carried out in a sensible way that does not put vulnerable consumers at more risk because they have no home care. Vaccinated aides should be offered extra shifts and overtime pay to ensure continuity of care. TIme is needed to schedule these arrangements - home care is not like a hospital, which can pull staff from other units or cancel elective procedures.
August 2021
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MLTC Disenrollments to Resume - After imposing a moratorium banning MLTC plans from involuntarily disenrolling members during the pandemic, DOH is again allowing disenrollments to resume on two grounds. See links to two state directives, the list of grounds for disenrollment in the model contract, and and info on which disenrollments are allowed here.
- LOCK-IN - DOH issued new guidance explaining more about the LOCK-IN rules that went into effect in Dec. 2020. See MLTC Policy 21.04: Managed Long Term Care Partial Capitation Plan Enrollment Lock-In (August 4, 20210 and Lock-In Policy Frequently Asked Questions - (Web) - (PDF). See more here.
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VACCINE MANDATE - New York joined a growing list of states Thursday, Aug. 26th mandating COVID-19 vaccinations for licensed home healthcare and home care agencies. The New York State Health Department’s Public Health and Health Planning Council unanimously passed an emergency regulation that will require workers at those agencies to have their first shots by Oct. 7. This expands the vaccination mandate announced on August 16th requiring all staff of nursing homes, other congregate care setings, and hospitals to have first shots by Sept. 27th. See more NYS COVID news here.
March 2021
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Healthfirst Medicaid Advantage Plus (MAP) Plan was required by the NYS Dept. of Health to temporarily increase home care for hundreds of members after it failed to "auto-forward" 789 appeals to the NYS OTDA Integrated Administrative Hearings Office (IAHO) for a hearing. Read about this new integrated appeal system that launched in 2020, and more about Healthfirst MAP"s mistake here. Download the letter sent by Healthfirst MAP plan to the affected members here.
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April 2021 Change for New Dual Eligibles - Medicaid Recipients who are First Enrolling in Medicare - While most MLTC members enroll directly in an MLTC plan on their own, some are automatically assigned to an MLTC plan when they first become enrolled in Medicare. These are people who had Medicaid as their only insurance prior to enrolling in Medicare at age 65 or after receiving Social Security Disability for 24 months. Most New Yorkers in this category are enrolled in "mainstream" Medicaid managed care plans, which are responsible for authorizing personal care or CDPAP services for members who need these services. These are the Individual & Family Plans on the NY Medicaid Choice website. See official brochures (English Spanish Russian). When they enroll in Medicare, until now, they were automatically transitioned to an MLTC plan for their home care. See MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC.
In April 2021, some new Dual Eligibles who received Medicaid personal care or CDPAP from their mainstream managed care plan will be "default enrolled" into a Medicaid Advantage Plus (MAP) plan instead of into an MLTC plan. Read more about this change here. Changes are happening for new Dual Eligibles who do not need home care as well, also described in this article.
Medicare Rights Center is hosting a webinar about these changes on Wednesday, April 14, 2021 at 3:00-4:00 p.m. -- Register here.
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The date to implement the restricted eligibility criteria enacted in last year's NYS 2020-21 Budget was April 1, 2021, and a new date is not yet known. The law set new minimum ADL thresholds for personal care, CDPAP services and MLTC enrollment. The law also overhauled the assessment system in a way that NYLAG and other advocates predict will impose intolerable delays in authorizing services and threaten to force consumers into nursing homes who could live at home with home care. Read about the changes here and see a webinar about them.
- 2,008 More MLTC Members who have been in Nursing Homes for 3+ months and who were approved for Institutional Medicaid will be Disenrolled from their MLTC Plans on April 1, 2021 unless they responded to this notice mailed to them by NY Medicaid Choice in mid-March. Read more about these dis-enrollments and members' rights here.
December 2020
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120-Day Transition Period for Wellcare MLTC members who were transferred to Fidelis on June 1, 2020, when Wellcare was acquired by Centene, ended on Oct. 1, 2020. Until October 1st, Fidelis or other new MLTC plan the former Wellcare member transferred to was required to continue the same hours of care for any former Wellcare member. Since then, Fidelis has reportedly tried to reduce hours for some of these former Wellcare members. These reductions can generally be challenged successfully. See this KNOW YOUR RIGHTS Fact sheet.
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See more on transition rights in this article- When an MLTC Plan Closes - What are the Members' Rights?
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Who is affected? Wellcare MLTC plan had members in the following counties prior to closure June 1st as follows. Anyone still in the plan as of May 2020, and possibly some who transitioned in the few months before, has transition rights.
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| Wellcare MLTC Enrollment |
Jan-20
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May-20
|
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ALBANY
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45
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45
|
|
ERIE
|
400
|
362
|
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NASSAU
|
315
|
289
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NEW YORK
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3,689
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3,292
|
|
ORANGE
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299
|
272
|
|
ROCKLAND
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195
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173
|
|
SUFFOLK
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490
|
422
|
|
ULSTER
|
169
|
157
|
|
WESTCHESTER
|
165
|
156
|
|
Total
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5,767
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5,168
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October 2020
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Nursing Home MLTC Disenrollments -- 1,672 more MLTC members received this notice that they will be disenrolled from their MLTC plans on November 1st because they have been in a Nursing home for 3+ months and were approved for Institutional Medicaid. About 70% of these reportedly are outside NYC, continuing to raise questions as to why so many more consumers outside of NYC are facing permanent nursing home placement than those in NYC.
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LOCK-IN - All MLTC members received letters from their plans in October informing them of the new "lock-in" rules that begin December. Download a sample letter and the insert to the Member Handbook explaining the changes. This will not affect current MLTC members unless they change plans after Dec. 1, 2020, in which case they will have a 90-day grace period to change plans for any reason, but then will be locked-in for 9 months unless they have good cause to change plans See more here.
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LOOKBACK delayed until April 1, 2021 - The NYS Budget exacted in April 2020 will require new applicants for Medicaid seeking Medicaid home care, MLTC, Assisted Living Program, and other community-based long term care services to submit up to 30 months of financial records, for them and their spouse. If they transferred assets during the lookback period, they will be denied home care or other long term care services for a "transfer penalty" period. This new requirement has been delayed from Oct. 1, 2020 to April 1, 2020. Read more about it here.
September 2020
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15,561 MLTC members were disenrolled from their MLTC plans on August 1st who were in a nursing home for more than 3 months and have been determined eligible for Institutional Medicaid. Before being disenrolled they received this notice of their right to request a fair hearing or to call NY Medicaid Choice to request an assessment by their plan for possible discharge. Only 19 consumers requested a fair hearing or called NY Medicaid Choice, and 20 contacted Open Doors, according to DOH. Only 200 other MLTC members were not disenrolled because they were identified by their plan or nursing home as having an active discharge plan.
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75% of all those disenrolled are in nursing homes outside NYC, even though 75% of all MLTC members are in New York City.
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NYLAG and other advocates have clients who were disenrolled despite having hopes to return home, and are concerned there are many more. The State notices say they can re-enroll within 6 months, but it's unclear what their rights are. Are they entitled to the same amount of care they received before entering the facility? May the plan refuse to re-enroll them? Or are they considered new enrollees, stripped of the right to receive the same hours unless the plan provides notice and proves that a change occurred that justifies a reduction? See MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care or CDPAP Services.
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Disenrollment Notice not sent to consumer's home address or to trusted family --NYLAG, The Legal Aid Society and other advocates wrote DOH and Governor Cuomo, demanding that residents' designated family members receive copies of the disenrollment notices -- but the notices are apparently being sent solely to the nursing home address. With families unable to visit because of the pandemic, residents have no help to request hearings or advocate to return home. Going forward, hundreds of MLTC members may be disenrolled each month as their stay in the facility reaches the 3-month threshold.
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Another batch disenrollment is scheduled for November 1, 2020.
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See more in the July 2020 Update below and here.
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DOH Moves Forward to Implement Restrictions on Who is Eligible for Personal Care, CDPAP and MLTC Enrollment and Assessment Changes Enacted in State budget April 2020 .
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NYLAG Evelyn Frank program conducted a webinar on the changes on Sept. 9, 2020. You can view a recording of the webinar, download the Powerpoint, and see other info on the changes here. The changes include a new minimum of two or three "ADLs" or Activities of Daily Living required to qualify for home care or MLTC.
- DOH proposed to amend state regulations to implement restrictions on eligibility for Personal Care, CDPAP and MLTC enrollment, and a new series of assessments to be conducted by NY Medicaid Choice (Maximus) instead of by the local districts and MLTC and managed care plans. The proposed regulations are posted here.
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NYLAG submitted extensive comments on the proposed regulations. A summary of the comments is on the first few pages of the PDF.
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NYLAG also commented on the State's request to CMS to amend the "1115 waiver" that governs MLTC to restrict eligibility for MLTC services to those who meet the new minimum In the same proposal, DOH also requested CMS' permission to passively enroll Medicaid recipients who do not need home care into Medicaid managed care plans when they become eligible for Medicare. NYLAG's comments will be posted soon.
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DOH proposed to amend the "1115 waiver" which governs the MLTC and Medicaid managed care programs in NYS to implement the new "lookback" to determine who is financially eligible to receive community-based long term care services including MLTC, personal care, and CDPAP.
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NEW "LOCK-IN Rule" Starts December 1, 2020 -
- For new enrollments or plan transfers on or after Dec. 1, 2020, MLTC enrollees may transfer to another MLTC plan:
- Freely during the first 90 days of a 12-month period or
- With good cause only during the last 9 months of a 12-month period. See list of "good cause" factors here.
- MLTC member may transfer to or from a PACE or Medicaid Advantage Plus (MAP) plan any time. This only affects the regular MLTC "partial capitation" plans.
- MLTC plans will send announcements and Member Handbook inserts early October 2020
- This change was enacted in NYS in 2018 but not approved by CMS until December 2019. See June 2018 DOH Medicaid Update for how DOH then planned to implement lock in.
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FAIR HEARINGS and "EXHAUSTION" MLTC APPEALS - DOH proposed to amend the state's Medicaid managed care regulations to incorporate the requirement to "exhaust" the plan appeal process before requesting a fair hearing. This requirement was added to federal regulations in 2016 and implemented in NYS in 2018. See this article. At the time, DOH implemented it through informal guidance (see links and summary in this article), and is only now formally proposing to amend the regulation.
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NYLAG submitted comments on these proposed regulations available here.
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See more about exhaustion and MLTC appeals here, including fact sheets, a recorded webinar, links to State guidance, and more.
July 2020
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On July 13, 2020, DOH issued GIS 20 MA/06 – MLTC Enrollees Receiving Long Term Nursing Home Care – “Batch” Disenrollment Process with Attachment I (Notice of Disenrollment )
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On July 2, 2020, NYLAG, Legal Aid Society, CIDNY, Empire Justice Center & other organizations wrote to Governor Cuomo, echoing their earlier letter to DOH (both attached in same PDF) demanding the state halt the mass expulsion of almost 20,000 MLTC members from their MLTC plans because they have been in nursing homes for more than 3 months.
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Who will receive the Notices of Disenrollment? MLTC members who have been in a nursing home for 3 months or more, whose financial eligibility for Nursing Home Medicaid has been approved (meaning they did the 5-year lookback). These nearly 20,000 people fall into two groups -- either they:
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were enrolled in the MLTC plans in the community, and were admitted to a skilled nursing facility after some acute episode, often with the expectation that they would return home, OR
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were never in an MLTC plan before -- they entered the nursing home, applied for and were approved for Nursing Home Medicaid, then were required to enroll in an MLTC plan (under a policy the State has now reversed).
DOH has asked MLTC plans to identify those members who have an "active discharge plan," who will not receive the noties and will not be disenrolled from the MLTC plans. However, DOH has defined this group so narrowly that many people who fully expect to return home will receive the notices - and may be disenrolled August 1st. See Dear Nursing Home Administrator Letter of June 11, 2020,
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Will their families or representatives receive a copy of the notice? The State has not answered this question, but NYLAG and other advocates fear that they will not. This means the resident may not get help they need to respond to this notice - as required if they expect to return home with home care.
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What can a representative or family member do to help someone who may be receiving this notice in mid-July, to make sure they can stay in their MLTC plan in order to obtain home care services needed to return home? BEFORE AUGUST 1st do one or both of the following:
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Request a Fair Hearing you will not be disenrolled August 1st if you make this request before August 1st.
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Call NY Medicaid Choice to report that you have a pending request for home care services, or a pending appeal or fair hearing, so need to stay in the plan, OR to request an assessment by the MLTC plan to return home. 1 -888-401-6582 (TTY: 1-888-329-1541). Either way, you will not be disenrolled August 1st.
If they have any problems requesting an assessment, or reporting a pending request, or other questions about this -- contact ICAN. 844-614-8800 ican@cssny.org
June 2020
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On June 29, 2020, NYLAG, Legal Aid Society, CIDNY, Empire Justice Center & other organizations sent a letter to DOH demanding the state halt disenrollment of almost 20,000 MLTC members from their MLTC plans because they have been in nursing homes for more than 3 months. With visitors banned from nursing homes, they'll have no help to appeal - and many will be forced to stay in the nursing homes, at risk of exposure to COVID. And COVID-19 has harmed people of color disproprotionately - in nursing homes in particular, not only in the overall population. See NYT article May 21, 2020 and NPR story April 2020.
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The disenrollment of MLTC members in nursing homes for more than 3 months is now happening, after being postponed when COVID-19 hit. But on June 11th we learned that in July 2020 the State will be sending notices to MLTC members in nursing homes for 3+ months that they will be disenrolled effective August 1, 2020. They will receive the revised notice posted here.
- Because of COVID-19, there are some relaxed rules for Medicaid home care and MLTC. Read about them here. There are also relaxed rules for Medicaid renewals here. See more about COVID changes for Medicaid here.
March 2020
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Nursing Home Residents Being Disenrolled from MLTC plans - UPDATE - DOH has now scheduled the Disenrollment notices to be sent to about 23,000 MLTC members in nursing homes for 3+ months STATEWIDE in April 2020, with disenrollment effective May 1, 2020. The revised notice is posted here. The State made many of the revisions in the notices that NYLAG and other advocates recommended in this letter -- compare the new notice to the original Notice posted here. DOH has asked plans and the Open Doors program to identify those members actively working on a discharge plan, so that they will not be disenrolled. The revised notice gives members an opportunity to request an assessment now, which will put the disenrollment on hold. If a member requests a Fair Hearing before May 1, 2020, the disenrollment will be put on hold as "Aid Continuing."
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Centene acquires Wellcare - Wellcare MLTC plan members will be transitioned to Fidelis on June 1, 2020 unless they select a different plan before then. They should NOT change plans yet - wait until they receive Notice from New York Medicaid Choice giving them their options. This notice should be sent out after April 1st. If they change plans before then, they risk losing Transition Rights - the right to have the new plan required to continue their same HOURS and other services for 120 days. See more on transition rights in this article- When an MLTC Plan Closes - What are the Members' Rights? Also see this Fact sheet.
Who is affected? As of January 2020, Wellcare MLTC plan had 5,767 members in these counties:
| ALBANY |
45 |
| ERIE |
400 |
| NASSAU |
315 |
| NEW YORK |
3,689 |
| ORANGE |
299 |
| ROCKLAND |
195 |
| SUFFOLK |
490 |
| ULSTER |
169 |
| WESTCHESTER |
165 |
| Total |
5,767 |
1,242,200 members of Wellcare's "mainstream" Medicaid managed care plan will also be transitioned to Fidelis. These are for consumers who do not have Medicare or other third-party insurance and do not have a Medicaid spend-down.
- ICS CLOSING: The One-Year Transition period for former ICS members who transferred to VNS Choice ends March 31, 2020. Read this Fact Sheet to know your rights.
February, 2020
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ICS CLOSING: The One-Year Transition period for former ICS members who transferred to VNS Choice ends March 31, 2020. Read this Fact Sheet to know your rights.
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On Feb. 20, 2020, DOH announced that it was postponing mailing Disenrollment notices to MLTC members who have been in nursing homes for 3+ months while it revises the Notices and makes systems changes. The notices were scheduled to be mailed outside NYC on Feb. 13th with disenrollment effective March 1st. NYC residents were scheduled to receive notices in mid-March effective April 1st. The new dates for mailing have not been set.
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ADVOCACY VICTORY ON REVISED NOTICES --
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On February 10th, NYLAG, joined by The Legal Aid Society, Empire Justice Center, and CIDNY, sent a letter pointing out PROBLEMS WITH THE DISENROLLMENT NOTICE & PROCEDURES. The original disenrollment notice is attached to the letter and posted here.
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On Feb. 21st, the State met with advocates who sent the letter, and agreed to make many of the changes requested by NYLAG and the other advocates. A draft of the revised notice shared with the advocates states:
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that the individual may call NY Medicaid Choice and request a plan assessment for a discharge plan, and that if they call before the disenrollment date, they will remain in the plan until the assessment is completed and they are notified of the plan's decision.
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That if they are disenrolled, they may re-enroll in the plan within 6 months without requiring a new Conflict Free assessment.
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The notices will be clearer about the right to request a Fair Hearing to oppose the disenrollment if they hope to return home.
The notice is being further revised, and will be posted here when final.
Still under discussion are various procedures including:
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where notice will be mailed -- whether solely to the nursing home address or also to the member's home address and to their designated representative (usually a family member), and
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which members will not receive the notices because they have "active discharge plans" -DOH has asked the MLTC plans to identify those members with "active discharge plans" who will not receive the disenrollment notices and will remain in the plan even though they have been in the nursing home for 3+ months, but advocates are concerned that many members actively trying to return home will be left out of that list, and will be disenrolled. See advocates' letter.
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What are rights of members who are reassessed but determined by the plan unable to return home? The notices and procedures are under discussion.
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What training will ALJ's and NY Medicaid Choice phone center staff receive?
- How many members of MLTC plans will be disenrolled because they are in nursing homes for 3+ months? On Feb. 17th, Syracuse.com reported that "65% of the members in Nascentia Health Options, the company’s managed long-term care plan that operates in 48 Upstate New York counties, will be disenrolled from the plan on March 1," and quoted a Nascentia administrator as saying that “'Across Upstate New York, 42% of MLTC members are permanently placed in a nursing home,...'” Using enrollment data from December 2019 (monthly enrollment reports available here), this would mean that approximately 24,000 MLTC members outside of NYC are in nursing homes and would be disenrolled. A State official unofficially stated that the number to be disenrolled statewide was about 22,000. Exact numbers have not been provided.
See Advocacy Letter 2/10/2020 for more information.
January 2020
Read more about these changes and download the notices being sent to consumers in this article. The article also has links to the State's original proposal to CMS to make this change, and to comments submitted by NYLAG and other advocacy organizations opposing the change, primarily because plans will be incentivized to avoid authorizing high-hour home care plans for those with extensive needs, since the plan can avoid high costs altogether if the member is placed in a nursing home and eventually disenrolled from the plan.
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CMS Also approved the 'Lock-In Provisions" - For the first time since MLTC became mandatory in 2012, members who enroll in a new plan after the effective date (not yet announced) will be barred from changing plans for 9 months, after the first 90 days enrolled in the plan. Stay tuned for more information about this. No procedures have been issued as of Jan. 22, 2020.
Both of these changes were approved in a CMS letter dated Dec. 19, 2019 approving revised "Special Terms and Conditions" of the 1115 Waiver, which governs the MLTC program and all Medicaid managed care programs in NYS.
October 2019
1. The FIDA Program is Closing December 31, 2019.
Read about what will happen for the 2520 current FIDA members who are all in NYC, Nassau and Westchester Counties in this article. Also see this Tool Kit by the Medicare Rights Center, with Fact Sheets about options for FIDA members and information about the Medicaid Advantage Plus insurance plans that most FIDA members will be switched to.
On Oct. 1, 2019, MLTC plans were required to further reduce the number of Licensed Home Care Services Agencies (LHCSA) they contract with. This change is described here. In the first reduction on Oct. 1, 2018, downstate plans (NYC, Long Island and Westchester) had to limit the number of LHCSA contracts to 1 LHCSA per each 75 enrollees (1:75). Now they must further cut their contracts to 1 LHCSA per 100 enrollees. In the rest of state, the limits last year were 1 LHCSA per 45 enrollees, and now 1 per 60 enrollees.
ADVOCACY WARNING: While consumers may be tempted to change MLTC plans in order to keep their aide if their MLTC plan stops contracting with the aide’s employer, the consumer has no right to keep the same number of hours in the new plan. The State DOH sees this as a “voluntary” transfer, unlike a transfer because the MLTC plan closed, in which members have “transition rights” to keep the same number of hours for 120 days. See MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration and this article on plan closings. Some advocates disagree and believe transition rights should apply. Consumers who transfer should ask the prospective new plan to confirm in writing that they will authorize the same plan of care – same hours/week – that the current MLTC plan has.
If an MLTC member is losing their longtime aide, they can ask their plan to use an EXCEPTION to the cap provided for in the DOH guidance posted in August 2018. There are TWO types of exceptions:
- “Continuity of Service” 3-Month Exception -- An MLTC plan may notify DOH that it is extending a LHCSA contract for three months to allow “continuity of service with a particular LHCSA or aide, to avoid disruption of service where geographic hardship exists or the region is otherwise hard to serve, or for the purpose of ensuring cultural or linguistic competencies.” DOH permission is not needed for the 3-month extension; the plan need only notify DOH at LHCSAExceptions@health.ny.gov.
- “Adequate Access to Services" - One-Year Exception - An MLTC plan may request an exception to the maximum number of allowable contracts ”by demonstrating, to DOH´s satisfaction, that additional contracts are needed to ensure adequate access to services in a geographic area. Adequate access to services includes special needs services and services that are culturally or linguistically appropriate." A three-month extension of the LHCSA contract is granted while the plan’s request is pending. If the request is denied, the plan has 3 more months to transfer the consumer to a different LHCSA – during that time it may contract with the same LHCSA and it will not count against the cap.
3. CDPAP Rate Cuts - As reimbursement cuts go into effect, lawsuit challenge continues.
See this article.
- ICS: As reported in the March and June 2019 MLTC Updates, Independence Care Systems (ICS) MLTC Plan closed March 31, 2019. Unless they picked and enrolled in a different plan, all former ICS members were transferred to VNS Choice. Under a special agreement between VNS Choice and State DOH, VNS may not reduce the services of former ICS members for one year from their date of enrollment in VNS or April 1, 2020, whichever is earlier, provided that the member was enrolled in ICS since January 2019. Consumers may call the ICAN Ombudsprogram program or other organizations through LawHelpNY if they have questions or problems receiving the same home care, adult day care, supplies, and other services that ICS provided.
- UnitedHealthcare Personal Assist MLTC plan closed September 1, 2019 in NYC, and Feb. 1, 2019 in six upstate counties. Guildnet MLTC closed Jan. 1, 2019.
Former members of all of these three plans are reminded that their new MLTC plan may not reduce their services for 120 days after their enrollment. See DOH MLTC Policy 17.02 and more on Plan Closings here. For former UnitedHealth MLTC members in NYC, this “transition period” will end Jan. 31, 2020. For former upstate UnitedHealth members, and former Guildnet members, their “transition” period already ended.
Plans may reduce services after the transition period only if the consumer’s health improved or for other limited reasons described in MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services. They must give advance written notice of a reduction, with the right to request a plan appeal with Aid Continuing. See more on appeals in this article. This is true whether the transition period is 120 days, for most MLTC members, or one-year, in the unique case of ICS members who transferred to VNS Choice.
ADVOCACY TIP: Advocates report that some plans have tried to reduce services simply because the new plan assessment allots fewer hours. This is not enough of a reason under MLTC Policy 16.06. Also, some plans have sent the consumer a notice of “authorization” of services, with no mention that the new amount is a reduction from before. This illegally deprives the consumer of the right to advance notice of a reduction with time to appeal the reduction and to continue receiving the same higher amount of hours as “AID CONTINUING” while the appeal is pending. See, for example, this Fair Hearing decision (May 2019).
Consumers may call the ICAN program or other organizations through LawHelpNY for help.
August 2019
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State Cuts Reimbursement in Consumer Directed Personal Assistance Program (CDPAP) - Lawsuit Filed Challenging Cuts.
On July 1, 2019, NYS Dept. of Health issued Managed Care Policy 19.01: Implementation of Fiscal Intermediary (FI) Rate Structure Enacted in the SFY 2019 NYS Budget (Appendices can be downloaded on MRT 90 page - click on 2019). The Policy implements changes in how CDPAP Fiscal Intermediaries are reimbursed enacted in the state budget in April 2019, which have the effect of cutting rates by $75 million in state funds ($150 including federal funds). The lawsuit was reported in Crain's NY Business on Aug. 14, 2019 and Spectrum News on August 1, 2019. The lawsuit claims that the rate cuts violate both federal and state requirements, and are so severe that will put many CDPAP fiscal intermediaries out of business, effectively ending the CDPAP program. More than 70,000 people receive MLTC or other home care services through the CDPAP program. For more info about the changes and the lawsuit see https://cdpaanys.org.
June 19, 2019
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UnitedHealthcare Personal Assist MLTC plan will close effective September 1, 2019. The plan had closed February 1, 2019 in six upstate counties - Albany, Broome, Erie, Monroe, Oneida, & Onondoga, requiring 2,263 members to change plans. During the week of June 17th, the remaining nearly 3,000 UnitedHealthCare enrollees in New York City will be notified that they must choose a new plan by contacting New York Medicaid Choice by August 20, 2019. Those who do not choose a new plan by that date will be auto-assigned. The new MLTC plan must continue their current plan of care for 120 days from the date that they transfer into the new plan, pursuant to New York State Department of Health MLTC Policy 17.02.
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ICS MLTC Plan closed April 1, 2019. The special ONE-YEAR transition rights for those ICS members who transferred to VNS CHOICE were described in our March Update below. Any former ICS members who are not receiving the same home care services or other services that ICS provided may contact the ICAN Ombudsprogram at 1-844-614-8800 or ican@cssny.org. While ICS members had a choice of any plan, they would receive ONE-YEAR transition rights only if they enrolled in VNS Choice. Based on the state's enrollment data, most ICS members appear to have chosen VNS Choice, as that plan's enrollment increased by over 5000 members in April 2019, which is nearly the number that had been enrolled in ICS.
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See more about transition rights when MLTC plans close here.
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FIDA PROGRAM TO CLOSE Dec. 31, 2019 - FIDA is the New York demonstration program to coordinate long term care and medical care from both Medicare and Medicaid. The demonstration began in 2014 and was only implemented in NYC, Long Island and Westchester. FIDA plans provide all Medicaid and Medicare services through one managed care insurance plan. a combination of an MLTC plan with a Medicare Advantage Plan. See ICAN FIDA FACT SHEET (English)(other languages)
The program has been scaled back, as many FIDA plans closed, and the state discontinued "passive enrollment" in Dec. 2015. See more here.
As of May 2019, there are 2,848 people enrolled in six FIDA plans. Most enrollees are in New York City, and the remainder in Nassau and Westchester. None remain in Suffolk.
The State has convened a stakeholder workgroup to discuss the future of integrated care after FIDA ends. See this website. The timeline for winding down the FIDA program is on slide 6 of the Second Stakeholder Session presentation on February 28, 2019. The steps are:
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In March 2019, FIDA plans were permitted to begin marketing to their FIDA members to promote their Medicaid Advantage Plus (MAP) products, as an alternative to FIDA. MAP plans are similar to FIDA in that they control and authorize all Medicaid and Medicare services. They are a combination of a Medicare Advantage Dual Special Needs Plan ("Dual-SNP") and an MLTC plan all in one. See ICAN Information on types of plans, including Medicaid Advantage Plus.
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Effective July 2019, no new enrollment is permitted into FIDA plans.
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October 2019 - If CMS finds that the Medicaid Advantage Plus plans in NYC, Nassau and Westchester Counties are equivalent to their sister FIDA plans, using a three-pronged test, members of those FIDA plans in the approved conties will be "crosswalked" (passively enrolled) in the sister Medicaid Advantage Plus plan of their FIDA plan. This means they will receive notice of their options, and if they do not choose another option, they will be auto-assigned to the MAP plan affiliated with their FIDA plan.
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If a county or plan does not pass the equivalency test, those FIDA members will be passively enrolled into an MLTC plan effective Jan. 1, 2020.
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In choosing the type of plan, remember that a FIDA or MAP plan includes all medical providers and prescription drugs. A prospective enrollee should make sure their preferred doctors and other providers are in the plan's network, and that their prescription drugs are on the plan's formulary. As an alternative, an individual may join an MLTC plan and retain their separate Medicare coverage - whether Original Medicare plus a Part D drug plan or a Medicare Advantage plan.
March 5, 2019 Update
- ICS CLOSING MARCH 31, 2019. As reported in January 2019 Update below, ICS MLTC plan will be closing at the end of March 2019, Following the "unofficial" letter of Jan. 7, 2019 announcing the closing from ICS CEO Rick Surpin, the NYS Department of Health sent all ICS members a letter dated January 25, 2019 explaining that those members who did not contact NY Medicaid Choice to enroll in an MLTC plan by Mar. 20, 2019 would be assigned to VNS Choice MLTC plan eff. 4/1/19. ICS members who move to VNS Choice will receive the same type and amount of services ICS provided for ONE YEAR, while those who join a different plan will have only the standard 120-day continuity of care provided for in the state's MLTC Transition policy MLTC Policy 17.02.
New Health Home. Also, ICS members who go to VNS CHOICE may enroll in the new ICS Health Home that will be under contract with VNS to manage care for some ICS members who transfer to VNS. Read a letter from ICS in English or Spanish about joining the ICS Health Home. Those interested in joining the Health Home should fill out the consent form and give it to an ICS staff person, email it to ICS at MSCDocMgt@icsny.org or fax it to 718-907-1670. Here is the form in English, Spanish, Russian and Chinese. Read the ICS Health Home brochure in English, Spanish or Russian. For questions call ICS at 1.877.ICS.2525. See more on the ICS website.
UPDATE ABOUT TRANSITION RIGHTS/CONTINUITY OF CARE in NEW MLTC PLAN. In the January 2019 Update, we reported that ICS members who transferred to a new plan for February 2019 would NOT be entitled to transition rights, meaning that the new plan was not required to continue their same ICS plan of care for one year (if they moved to VNS Choice) or 120 days (if they moved to any other MLTC plan). The State Dept. of Health later revised this policy. As long as an individual was a member of ICS in January 2019, if they transferred to a different MLTC plan effective February 2019 or later, they would have transition rights in the new plan (one year for VNS Choice and 120 days for any other plan).
NEW: If an ICS member moved to an MLTC plan other than VNS Choice effective February 2019 or later, they may still move to VNS CHOICE and receive the special one-year transition rights/ continuity of care -- with these limitations --
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The member must have been enrolled in ICS during January 2019.
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The member must transfer to VNS CHOICE effective December 2019 or earlier in order to be entitled to transition rights. If they transfer to VNS Choice effective January 2020 or later, they do not have transition rights.
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The one-year special VNS transition period begins on April 1, 2019 and ends on March 31, 2020 if the member switches to VNS Choice effective on or after April 1, 2019. If the member switched to VNS Choice effective March 1, 2019 (having transferred from ICS to a different MLTC plan in February 2019), then the one-year transition period will end on February 28, 2020.
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What AMOUNT and TYPES of services must VNS Choice continue to provide for a former ICS member who first transferred to a different MLTC plan in or after February 2019, and then moves to VNS Choice in or before December 2019?
The individual is entitled to the same amount and types of services that ICS had provided ONLY IF the new MLTC plan to which they switched is still providing that same plan of care. Since the new MLTC plan is required by MLTC Policy 17.02 to provide the same plan of care for 120 days, anyone who transfers to VNS Choice during the 120-day transition period is assured of receiving the same services that ICS had provided. If the individual transfers to VNS Choice after the 120 days has lapsed, and the new MLTC plan has already reduced services, then DOH has stated that VNS CHOICE is only required to provide continuity of care at the reduced level given by the last MLTC plan. However, if the proposed reduction in services by the new plan has not gone into effect, because the individual is entitled to "Aid Continuing" pending the appeal or because she won the appeal, then VNS Choice must continue the same services that ICS had provided.
To reduce services, the plan must send the member an Initial Adverse Determination notice that complies with MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services. If the member requests a Plan Appeal of the reduction, if the Plan denies the appeal, it must then send a Final Adverse Determination notice, which also complies with MLTC Policy 16.06. The member may then request a Fair Hearing. If the member requests the Plan Appeal and then, if needed, the Fair Hearing quickly within the short 10-day deadline, she will be entitled to Aid Continuing, which prohibits the plan from reducing services as proposed until the appeals are held and decided.
See more about Plan Appeals and the Notices that the plan must provide of any reduction here. Download this Fact Sheet about MLTC Appeals by NYLAG EFLRP.
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Neither the "Lock-In" Rule (described in January 2019 Update) or the Removal of Permanent Nursing Home Care from the MLTC benefit (see Oct-Nov 2018 update) have been implemented. Both changes were enacted in the 2018 NYS Budget, but the state is still awaiting CMS approval for these changes.
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NYS Budget proposals potentially impact access to long term care services. Gov. Cuomo again proposed to eliminate "spousal refusal," and has proposed sweeping changes in the Consumer Directed Personal Assistance Program. Read NYLAG Testimony about these and other Medicaid changes. Also see testimony and budget agenda of Medicaid Matters NY and more information on the CDPAP changes here.
January 2019 Update
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New "Lock-In" Rule On Hold Pending CMS Approval - The date has been indefinitely postponed from Dec. 1, 2018 to bar MLTC enrollees from changing MLTC plans after the 1st 90 days in a plan. This State "lock-in" law is described here. This change requires approval by CMS which is still pending. For the time being, MLTC members may change plans any time. However, they should be aware that when a member "voluntarily" moves to a different plan, they do not have "transition rights," which mean that the new plan does not have to provide the same services in the same amounts as the previous plan did. These transition rights, under DOH policy, only apply if an MLTC plan closes, as happened for Guildnet and as will happen for ICS, described below. (See this article -- When an MLTC Plan Closes - What are the Members' Rights? and see Oct-Nov 2018 Update below re Guildnet closing.) If the new plan does reduce a member's hours, however, there are still claims under due process and DOH MLTC Policy 16.06 for challenging a reduction. Contact ICAN for more infomation.
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Independence Care System (ICS) MLTC plan Announces Closing on March 31, 2019. As reported in Crain's New York Business on January 10, 2019, and as announced by ICS President Rick Surpin in an e-mail sent to colleagues on January 8, 2019, as reported in Crain's,
"...The state Department of Health has agreed to a deal with Independence Care System to wind down its managed long-term care plan by March 31 and transition members to a different insurer.
"If ICS' about 5,800 MLTC members do not pick a new plan by April 1, they automatically will be enrolled in VNSNY Choice...MLTC plan.... Members who join VNSNY Choice will be "guaranteed the same level of services they currently receive for one year," ICS said. Members who pick a different plan are eligible to maintain their same level of service for 120 days. ...
...Independence Care System, founded in 2000, specializes in providing coverage to people with physical disabilities and had struggled financially due to the more intensive services required by its members. ICS has a significant portion of members requiring 12- or 24-hour care by home health aides, according to disability advocates. The state's managed long-term care program is designed to provide nursing home-level care to people who are chronically ill or disabled with the goal of allowing them to remain at home.
"Caring for a high proportion of members with significant to severe disabilities made it increasingly fiscally unsustainable for ICS to continue as an MLTC plan," ICS said in its announcement.
- Under the state's Transition policy MLTC Policy 17.02: used when a plan closes, ICS members will receive an official letter on about Feb. 1, 2019, which is 60 days before the plan closing. That letter will give them the choice of moving to VNS Choice or selecting another MLTC plan. As Crain's reported, a special bonus for transferring to VNS Choice is that VNS Choice must keep the same services and hours of care that ICS provided for ONE YEAR. This is much longer than the standard "transition period" when a plan closes, which is 120 days. If they do nothing, they will be automatically assigned to VNS Choice.
- WARNING: ICS members should NOT transfer plans until they receive the official letter about ICS closing on around Feb. 1, 2019. If they transfer now (which would be effective Feb. 1st), under State DOH policy, they are not entitled to "Transition rights" under MLTC Policy 17.02. This means that the new plan is allowed, under DOH policy, to reduce their home care services when they enroll, or any time after. People who wait to change plans after they receive the official letter, on the other hand, have the right to keep their same services and hours of care for ONE YEAR if they go to VNS Choice, or for 120 days, if they pick any other plan. To pick VNS Choice, they can do nothing and just be automatically assigned.
- If an ICS member, having heard unofficial reports that it may close, already changed plans, and had their hours reduced, they may be able to challenge the reduction in hours. See information about new appeal procedures. They can call ICAN - the Ombudsprogram for MLTC members -- or call NYLAG at 212-613-7310 (Mon, Wed, Fri) or 212-613-5000 (M, W, Thursday 9-3 PM). Since September 2018, ICS enrollment has dropped by about 250 - raising fears that these members transferred out of ICS out of concern that they might be left without care if the plan closes. See enrollment chart.
- TIP: ICS Members may want to request their medical record from ICS, so that if the new plan tries to reduce their hours, they have the record of the care ICS authorized. AL MLTC members have the right to request their medical record. See Managed Long Term Care Guide p. 17. We recommend asking for all “UAS assessments” (Uniform Assessments by plan nurse), service authorizations, plans of care, and case management notes since you first received your current service plan. For example, if ICS increased your services from 24 hour live-in to 24-hour split-shift in May 2015, you would ask for the above documents since the MAY 2015 authorization.
Here’s where you can email or fax your request:
Email: MSCDocMgt@icsny.org Fax #: 718-907-1670
What happens after the transition period ends - 120 days or One Year in VNS Choice - May the new plan reduce member's hours? See this article about the member's rights to keep their same services unless the plan can prove that their condition improved, or some other change occurred.
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
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GUILDNET MLTC - This notice was sent by New York Medicaid Choice to all Guildnet MLTC members on Oct. 19, 2018, stating that if they don't select a new plan by 12/19/2018 they will be auto-assigned to a new plan for January 1st. The notice states, "The Plan you select will continue to honor your current plan of care for 120 days from the date that you transfer to the new plan." These "transition rights" were authorized by the NYS DOH MLTC Policy 17.02 which requires continuity of care in the new plan after a plan closing. For Guildnet FIDA, See item #3 below.
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A few notes about the Guildnet closing and some tips:
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Priority of Keeping Member's Long-time Home Care Workers. One key factor in selecting a new plan is to pick one that contracts with the same Licensed Home Care Services Agency (LHCSA) or CDPAP Fiscal Intermediary through which the member has her home care aides. Please note that another change that went into effect October 1, 2018 is that MLTC plans were required to reduce the number of their contracts with LHCSAs, which means that many MLTC members may be losing a long-time aide. It is therefore critical to find a plan that will enable the client to maintain a longtime trusted aide. This change is described here, with links to relevant documents, including the DOH guidance posted in August 2018.
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Another factor in selecting a plan is that the plan will continue the same hours that Guildnet has authorized after the end of the 120-day transition period, during which the new plan must continue the old hours. While this would be desirable to confirm to prevent the need for appeals down the road, it may not be possible to obtain a plan's commitment to continue this amount of hours. Therefore, we suggest that once you identify a plan that contracts with the same home care provider agency, that the member contact NY Medicaid Choice and request to be enrolled in that plan. Under Policy 17.02, they do not have to be assessed by the new plan.. It says,
"... 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.
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MLTC members - What happens after 120 days? [FIDA - 90 days, see more below] The new plan must conduct an assessment within 30 days, but may not reduce hours until after the 120 days. While Policy 17.02 does not say, another policy clearly limits plans from reducing hours, unless there is a specific change in the enrollee's condition or circumstances since the original plan of care was authorized, and that fewer hours are needed because of that change. Please review MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services. This guidance provides explicit limitations on when plans may reduce hours, and applies to the new plan to which a member transfers when an old plan closes. If plan claims a justification for reduction, it must send Notice of Reduction at least days before the proposed effective date of the reduction, with the right to request a plan appeal (internal appeal), with Aid Continuing if the appeal is requested before the effective date. See more about the new plan appeal or exhaustion requirements here.
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Get Case Record from Guildnet. Especially for consumers receiving 10+ hours/day or 24/7 care, they should request from Guildnet now, before they are transitioned, copies of their case record, including at least the last biannual Uniform Assessment System (UAS) assessments, and the last two authorizations or notices authorizing their current plan of care. If they've received the current plan of care for a longer period of time, they might request these documents going back to the first time that Guildnet authorized their current plan of care. These records may be useful if a new plan tries to reduce hours.
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How to request records: The MLTC Enrollee Rights that is contained in every MLTC plan model contract states in part, "You have the Right to get a copy of your medical records and ask that the records be amended or corrected." See model contract Appendix L (p. 153 of PDF) This right is also in the NYS DOH Managed Long Term Care Consumer guide, available here (see p. 17), and in all plan member handbooks. We are finding out the best way to request records. Until further information is available, we suggest emailing it to gnprovrel@jgb.org or mailing it to GuildNet Member Services 250 West 57th Street 10th floor New York, NY 10107 or call Member Services at New York City: 212-769-7855 Brooklyn: 718-495-2200 Toll Free: 800-932-4703
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If you want your records to be released to a representative or anyone other than you, include a HIPPA release - OCA Form No. 960 - Authorization for Release of Health Information Pursuant to HIPAA
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If a Guildnet member arranges to be assessed by a new plan, whether referred by NY Medicaid Choice or by the member reached out to a new plan, and the new plan says they would give fewer hours than Guildnet had authorized, the individual should not sign anything that might be interpreted as agreeing to this reduced plan of care. If they do sign an enrollment agreement, or even sign a reduced plan of care, we believe advocacy can be done to protect the member's rights to continuity of care under Policy 17.02. However, this will likely require advocacy once they transfer.
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.
- LOCK IN - If member is unhappy with their new plan, may they change plans? Think twice before changing plans again for two reasons.
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NEW LOCK IN RULES - If hey change to the new plan on December 1st or later, new "lock-in" rules go into effect. These will allow MLTC members to change plans only in the first 90 days after enrollment. After, that they are locked in for the next nine months and may only change plans for good cause. This change has not yet been approved by CMS as of Oct. 29, 2018 so it may not go into effect on December 1st as the State has proposed. Here is the proposed notice DOH will send to all MLTC members explaining the new lock-in rule.
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Second, if the member changes plans again, State policy has been that changing plans a second time after a plan closing is a "voluntary" change, so the 2nd plan is not required to give the 120-day continuity rights. The State's view is that the enrollee has agreed to the plan's plan of care and number of hours of service, so has agreed to any reduction of hours that entails. Advocates may disagree with this policy, which may be subject to challenge, but as of now this is the State's policy.
- FIDA CLOSINGS - Four FIDA plans are also closing in January 2019:
- Guildnet GoldPlus FIDA plan - NYC only (418 members)
- Village Care Max Full Advantage NYC only ( 23 members)
- MetroPlus FIDA NYC only (205 members)
- AgeWell NY FIDA plan - NYC, Suffolk, Nassau, & Westchester (247 members) -- NOTE that Agewell was the SOLE FIDA plan in Suffolk county.
- GUILDNET FIDA - These notices were sent by Guildnet and by New York Medicaid Choice to all Guildnet Gold Plus FIDA plan members in early October 2018, stating that if they don't select a new plan by 12/31/18, they will be auto-assigned to Healthfirst AbsoluteCare FIDA plan for January 1st. As the notices state, consumers who are assigned to Healthfirst FIDA have transition rights to continue receiving services, including homcare, at their current levels for 90 days.
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.
- 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:
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Guildnet is terminating all of its health insurance products in New York State effective 1/1/2019, including the following plans shown with enrollment as of August 2018 (TOTAL - 8,211 members - all in NYC):
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Guildnet Medicaid Advantage Plus - 478 members
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Guildnet Gold Plus (FIDA) 417 members
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Guildnet MLTC - 7,316 members
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UnitedHealthcare is no longer offering their partial-capitation MLTC plan in the following counties effective 2/1/2019, shown with enrollment as of AUGUST 2018:
| ALBANY |
103 |
| BROOME |
266 |
| ERIE |
181 |
| MONROE |
534 |
| ONEIDA |
91 |
| ONONDAGA |
288 |
| Total |
1,463 |
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In both cases, per MLTC Policy 17.02, enrollees will receive advance 60-day written notice of the change, with an opportunity to choose a new plan before the effective date. or if they do not choose a new plan, they will be auto-assigned to a new plan effective Jan. 1, 2019.
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Guildnet enrollees will receive notice the week of 10/15/2018, and must choose a new plan by 12/19/2018 to avoid auto-assignment. Under MLTC Policy 17.02 they can call NY Medicaid Choice which will do a "warm transfer" to their selected plan, without the need for a Conflict Free assessment (CFEEC).
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WARNING: Please note that it is not clear exactly what date NY Medicaid Choice will begin doing "warm transfers," without a CFEEC. Until clarification is received, we advise Guildnet members to remain in Guildnet until they receive the letter in mid-October explaining their options.
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UHC enrollees will receive notice in November regarding the plans closing effective Feb. 1, 2019; details to come
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DOH said that Guldnet MLTC and UHC members will be randomly auto-assigned to a different plan if they do not select one by the deadline. However, DOH indicated that NY Medicaid Choice will conduct outreach with members to try to assign the member to a plan with the same licensed home care agency (LHCSA) in its network to promote continuity of care. FIDA auto-assignments will be fully “intelligent” based on Primary Care Provider and LHCSA.
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Transition Rights - Continuity of Care -- These transitions are covered by MLTC Policy 17.02, with the following consequences:
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The new plan must continue to honor the same service plan with the same providers and same amount of home care and other services for 120 days after the effective date, "or until the new plan has conducted an assessment and the enrollee has agreed to the new plan of care."
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This is true whether the enrollee chooses their own plan before 12/19 or allows themselves to be autoassigned. However, it is not clear whether members have this protection YET. We are waiting for clarification about whether members who already are switching to another plan effective October 1st are protected by these continuity protections. Until this is confirmed, members should STAY IN THEIR CURRENT PLAN and wait for official notice before they switch plans.
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Those who call NYMC before 12/19 to choose their plan will be able to do a “blind enrollment” (no pre-enrollment conflict-free assessment) Again, it is not clear whether members can do this now, or must wait til after Oct. notices go out to Guildnet members. Until this is clarified, we suggest that they remain in their current plan.
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These transitions are subject to the new MLTC Lock-In policy that is effective for changes in plans 12/1/18 or later… New guidance was just issued on this. See Licensed Home Care Services Agencies (LHSCA) Contract Limitation Guidance – 08.17.2018
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Guildnet enrollees will have 90 days from the effective date of their enrollment into a new plan, if on 12/1/18 or later, to switch plans (e.g., if they don’t like the plan they were autoassigned to)
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After the 90 days, they will be locked into their plan for 9 months unless they can establish good cause
3. POLICY ISSUED IMPLEMENTING restriction on the number of Licensed Home Care Services Agencies that an MLTC plan may contract with, beginning Oct. 2018.
- The budget change is described here, with links to relevant documents.
- The DOH guidance posted in August 2018 sets forth an Exception process:
"An MLTC plan may request an exception targeted to specific patient needs. These include, as set forth below, continuity of service with a particular LHCSA or aide, to avoid disruption of service where geographic hardship exists or the region is otherwise hard to serve, or for the purpose of ensuring cultural or linguistic competencies." In part, if a plan stops contracting with one LHCSA to comply with the new limits, and an "enrollee wishes to be cared for by one or more home care workers employed by the current LHCSA, the MLTC plan may continue contracting with the current LHCSA for the purpose of continuing that enrollee´s care by those home care workers for up to three months." MLTC plans must notify DOH at LHCSAExceptions@health.ny.gov of the three–month extension of the LHCSA agreement. The guidance does not explain how an enrollee may request this extension.
- "An MLTC plan may request an exception to the maximum number of allowable contracts by demonstrating, to DOH´s satisfaction, that additional contracts are needed to ensure adequate access to services in a geographic area. Adequate access to services includes special needs services and services that are culturally or linguistically appropriate." Again, the guidance does not explain how an enrollee may request that the MLTC plan request an exception.
- On Aug. 21, 2018, the CEO of Guildnet sent a letter to all Guildnet employees stating that its Board of Directors had decided the previous day to close Guildnet effective 12/1/18. The letter (posted here) states that the plan will be working closely with the State Dept. of Health on the transition of its members to other MLTC plans. On August 28, 2018, Crain's NY Business reported that the NYS Dept. of Health (DOH) confirmed that "GuildNet had filed a request with the state to stop offering its MLTC plan. It said the nonprofit has stopped enrolling new members. 'The department is working with GuildNet to ensure continuity of care as it finalizes particulars of this plan,' a spokeswoman said." See this article which explains member "transition rights" when an MLTC plan closes. It is very important that members do not panic and switch to other plans until there is official notice from the State. People who switch plans now will not be protected with "transition rights" under MLTC Policy 17.02 that is described here. Read about consumer advocates' concerns about the State's transition policy here. As of August 2018, Guildnet has 7,316 MLTC Members in its MLTC plan, 478 in its Medicaid Advantage Plus plan, and 417 in its FIDA plan - all in NYC. Crain's implies that all three plans are closing but this has not been confirmed. Guildnet's enrollment has markedly decreased in the last year or two, from being the second largest MLTC plan in NYC to the 10th largest plan currently. See this chart. Read more about the Transition Policy when plans close here.
July 2018 Update
- NEWS OUTLETS REPORT POTENTIAL CLOSING OF INDEPENDENCE CARE SYSTEMS (ICS) MLTC PLAN later in 2018. See this article, with advice given by ICS in a memo to its Member Council, "It is in each ICS member's best interest to stay at ICS until notification comes from DOH because the extended continuity of care will only be offered to people at ICS at the time of notification." The "continuity of care" refers to the right of members of plans that close to receive their same plan of care for 120 days after they transfer to a new plan, under NYS DOH "MLTC Policy 17.02: MLTC Plan Transition Process – MLTC Market Alteration."
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NYS LEGISLATURE ENACTS CHANGES IN MLTC IN STATE BUDGET. The NYS Dept. of Health is now preparing to implement various changes in the MLTC program that were enacted in the NYS Budget in April 2018.
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Beginning December 2018, MLTC members will no longer be able to switch plans after a 3-month grace period after their enrollment. See this article for more about this change.
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MLTC members who are permanently placed in a nursing home for more than 3 months will be disenrolled from the MLTC plans. .
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Read about these and other MLTC changes in this article.
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The new requirement to request an internal Plan Appeal of an Initial Adverse Determination of a managed care or MLTC plan, before one may request a Fair Hearing, began May 1, 2018. See more about these changes here. Find a link to watch a recorded webinar about these changes here.
March 27, 2018 update
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The NYS Dept. of Health now has web pages for both MLTC and Mainstream Managed Care plans about the new "exhaustion" requirement -- members must now first appeal decisions of the plans in an internal "plan appeal" before requesting a fair hearing. For links to these pages, and to learn about webinars sponsored by the NYS Dept. of Health and by NYLAG Evelyn Frank Legal Resources Program about the changes, click here.
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The final NYS budget is anxiously anticipated, with the legislature hoping to have it completed before March 30th, ahead of the weekend and Passover and Easter travel. To read about some of the proposals that affect Managed Long Term Care and Medicaid recipients generally, see this article.
February 28, 2018 update
- On Feb. 27, 2018, the starting date for the new requirements that MLTC member request Internal Appeals with their MLTC plans before requesting a Fair Hearing has been pushed back to May 1, 2018, from April 1, 2018. See this news article for information on the changes, and also this article that explains the new rules in more detail.
December 2017 Update
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.
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Guildnet - About 3,000 former members of Guildnet MLTC plan in Long Island and Westchester who transitioned to another plan after they heard Guildnet was closing, have received this Sept. 29, 2017 letter from the State telling them they may request that their hours be restored to the amount Guildnet authorized, if the new plan reduced their hours. To request that hours be restore, they must call New York Medicaid Choice before Dec. 29, 2017 at 1-888-401-MLTC or 1-888-401-6582. If they are still eligible for Medicaid, the new plan should increase their hours to the amount Guildnet authorized. If you have called NY Medicaid Choice and cannot get your former hours restored to the amount Guildnet gave, you can call NYLAG Special Litigation Unit at 212-613-5032 or call ICAN Ombudsprogram at 1-844-614-8800
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The remaining 930 Guildnet members in Nassau, Suffolk & Westchester counties will received in mid-October that they have 60 days to select a new plan, or they will be auto-assigned to another plan The new plan must continue the same services that Guildnet provided for 120 days or until the member agrees to a change.
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See more about the Transition Policy, status of plan closings, and SUGGESTED CONSUMER STRATEGIES to protect consumers from reductions in hours in this transition in this article.
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North Shore LIJ MLTC - New York Newsday publicized the closing on September 1, 2017, Northwell to end long-term care plan that covers 6,000 elderly, On September 22, 2017, North Shore sent this letter to all of its 5,645 members in Nassau, Suffolk, and New York City. The letter informs members that the plan is closing 12/31/17. and that unless they enroll in a different plan before 11/10/17, they will be auto-assigned to Centers Plan for Health Living effective January 1, 2018. While the letter does not specifically say it, North Shore LIJ members should have the protections regarding keeping their same services, described above in new DOH MLTC Policy 17.02. See this article for more about the policy, advocate concerns about the policy, and consumer strategies to ensure that services are not reduced in the transition. If hours were or are cut when they transfer to a different plan, call NYLAG Special Litigation Unit at 212-613-5032 or call ICAN Ombudsprogram at 1-844-614-8800
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See more about plan closings here, including which FIDA plans will be closing in January 2018
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 -
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Home care workers, including CDPAP personal assistants, are entitled to increases in wages in 2017, with further increases in 2018. See
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Appellate Division decisions strike down state rule that allows 24-hour live-in aides to be paid only 13 hours/day. Decisions state that 24-hour case home care workers must be paid for all 24 hours if they are “nonresidential,” meaning they do not exclusively reside in the consumer's home. The decisions were based, in part, on rejecting a 2010 state Dept. of Labor policy guideline RO-09-0169 Live-In Companionsas in conflict with state minimum wage regulations. Tokhtaman v. Human Care, LLC (1st Dept. 2017 NY Slip Op 02759); Andreyeva v. NY Home Att. Agency; Moreno v Future Care Health Serv. (2nd Dept.)
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.
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
- HomeFirst, an MLTC plan run by ElderPlan, announced it is also pulling out of Suffolk County. As reported in Crain's Health Pulse, this is "... the latest example of an insurer narrowing its geographic coverage for chronically ill and disabled members, the health plan confirmed on Friday. The decision 'was driven by the difficulties we encountered effectively staffing and serving the needs of members across such an expansive geographic area,' said a spokeswoman for the nonprofit MJHS, which runs Elderplan. The insurer will continue to cover members' services until they pick a new plan, she said.
Crain's further reported, "The move follows the exit of another nonprofit managed long-term care plan, GuildNet, from Suffolk as well as Nassau and Westchester counties as of June 1. The two plans had covered 41% of the 5,735 managed long-term care enrollees in Suffolk County as of March. The state Department of Health is "closely tracking" the transition of members in Suffolk County following the exits of GuildNet and Elderplan, a spokeswoman told Crain's. There are still 10 plans offering coverage in the county, including Fidelis Care and North Shore-LIJ Health Plan. Earlier this month in response to GuildNet's exit, the department had said there was "ample capacity and choice" in the managed long-term care program."
- Guildnet Withdrawal from Nassau, Suffolk and Westchester - On May 13, 2017, NYS Dept. of Health sent over 4000 letters to members of Guildnet MLTC plan in 3 counties - Nassau, Suffolk and Westchester, clarifying information sent by Guildnet in April. (See April 2017 update below). The State Health Dept. clarified that members are not required to find a new plan by June 1st, and may remain in Guildnet after that date, and that Guildnet is required to continue providing them with MLTC services. The letter does confirm that this MLTC plan has requested to stop providing services in these 3 counties. However, the letter states Guildnet must continue providing services "until a smooth transfer can be completed to your new plan." Still not specified is what happens if the individual cannot find a plan willing to provide the same hours as Guildnet authorized. Advocates maintain that members have the right to continue the same amount of services. See letter posted here
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
- Guildnet notified members in Nassau, Suffolk and Westchester that its MLTC "...will no longer offer Managed Long Term Care (MLTC) services" in these counties "effective June 1, 2017.” The notice sent in late March further states, “It is important that you select a new MLTC plan before May 18, 2017 to assure a smooth transfer to your new plan." Download a copy of the notice sent to Guildnet's over 4000 members in these 3 counties. Here's more info about this change:
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The letter further states, "You will continue to receive services from GuildNet until your transfer to your new plan is complete." Advocates are informed that members WILL CONTINUE to receive Guildnet MLTC services even after June 1, 2017 if they do not select a new plan.
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Members will not be "auto-assigned" to a new MLTC plan if they do not enroll in one on their own.
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Despite the letter's wording, advocates are informed that if other MLTC plans do not authorize the same amount or type of services that the member now receives from Guildnet, they do not have to change plans. Also, many MLTC plans are backed up and cannot schedule assessment visits until June or later. Members may stay in Guildnet after June 1, 2017. This is true regardless of what members may be told by staff of Guildnet, New York Medicaid Choice, or other organizations.
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Also, some members have been notified that Guildnet will no longer contract with the home care agency that employs their home care worker. Advocates were told by the State Dept. of Health that Guildnet must do "single case" agreements with home care agencies. This means Guildnet will still pay the home care agency to continue to provide services to individual members after June 1st, even if that home care agency's contract with Guildnet ends on June 1st.
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The Guildnet Gold Plus FIDA Plan continues to be offered in Nassau County and Guildnet Medicaid Advantage Plus (MAP) Plans continue in Nassau and Suffolk Counties
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Transition Policy Requested. Advocates are asking the State to require the new plans (to which former Guildnet members are transferring) to continue the same services and same number of hours that Guildnet authorized. So far, the State has not agreed to issue this "transition policy." Transition policies require MLTC plans to continue the same services for 90 days that the consumer received before enrolling in MLTC, when the consumers are mandated to transition from fee-for-service personal care or CDPAP to MLTC. See, e.g. MLTC Policy 13.13, MLTC Policy 13.01 (revised)(period was later extended from 60 to 90 days in MLTC Policy 13.10) (All MLTC policy directives available at https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm). The same protection should apply in this situation, where a plan is effectively closing down. Advocates contend that the new plan should only be allowed to reduce services below the amount Guildnet had authorized if there is a change in the member's needs or circumstances, after giving proper advance notice of hearing rights. See MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services
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The Guildnet letter does not give contact information for ICAN - the Independent Consumer Advocacy Network that contracts with the State Dept. of Health to provide information and advocacy for consumers about MLTC, FIDA, and other managed care plans. Members with questions or who have problems keeping the same hours, or facing disruptions in their care should call ICAN. Phone: 844-614-8800
TTY Relay Service: 711 Website: icannys.org e-mail: ican@cssny.org
- Who IS AFFECTED – as of March 2017 - as shown in this chart comparing with Nov. 2016 enrollment, based on DOH enrollment data
- 35% of all 5,735 MLTC members in SUFFOLK (1,990 members)
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27% of 6,438 MLTC members in NASSAU (1,753 members)
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10% of 4,685 MLTC members in WESTCHESTER (451 members)
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Background - In November 2016, as reported in the NYLAG MLTC news update article, Guildnet notified the State Dept. of Health that it "will no longer enroll members in Nassau, Suffolk and Westchester counties, according to a letter its chief sent to the state Department of Health. Alan Morse, CEO of GuildNet, told the Cuomo administration the 'calamitous state of reimbursement' made it no longer feasible to operate because the program was incurring 'substantial deficits.'" See story reported in Politico dated Nov. 23, 2016. On January 13, 2017, Crain's Health Pulse reported that Guildnet announced that it would hold off on giving the State the formal 90-day notice required before it exited from any counties. Crain's quoted Alan Morse, the CEO of Guildnet, "We said we would hold off on giving them formal notice until we figured out how well they would address our needs and how we're going to make the program work," with Mr. Morse referencing MLTC reimbursement rates.
Please see archives for past articles:
Guildnet closing
ICS closing
LHCSA Cap 10-2019
Plan closings 10-2019
what can family do re NH disenrollment?
what if disenrolled - NH?
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