The New Face of Long Term Care (MMLTC) 


Managed long-term care is becoming a reality in New York State for all those older and disabled individuals who have been covered by Medicaid. In 2012 the program began to be phased in county by county. That process will continue through 2014.

Individuals are required to join a state-paid Medicaid, managed long-term-care plan. This Managed Care Organization (MCO) will coordinate services for participants and direct them to particular doctors, hospitals, out-patient facilities, nursing homes, etc.

This abrupt change in policy reflects a broadening consensus among the states that managed care is more efficient, both for patients and the state.

Mandatory Enrollment
Enrollment in a Medicaid Managed Long Term Care (MMLTC) plan is mandatory for persons who (1) are applying for or currently receiving certain Medicaid home care or other community-based, long-term-care services; (2) are dually eligible (i.e., have Medicare and Medicaid); and (3) are 21 years of age or older.

MCO plans are insurance companies that are paid a monthly rate by New York State’s Medicaid program for each person enrolled. The plans take over the work of the local Medicaid office which did a similar job in determining whether home care was needed and, if so, for how many hours.

Payment for an MCO plan is capitated, that is, the government pays a flat fee to the plan for each member it covers regardless of how many treatments or hours of care the plan provides to that member.

Two types of managed-care plans are available:

  1. Fully-capitated plans — the Program for All-Inclusive Care for the Elderly (PACE) plan and the Medicaid Advantage Plus plan — which cover ALL Medicaid and Medicare services (i.e., primary and long-term and acute care); and

  2. Partially-capitated plans currently recruiting members in New York City include GuildNet, CenterLight Healthcare, Independence Care System, Elderplan, Aetna, and the Visiting Nurse Service.

Services Available
  • Home care, including:
    • Personal care (i.e., home attendant or housekeeping)
    • Certified home health agency services (home-health aide, visiting nurse, visiting physical or occupational therapist)
    • Private-duty nursing
  • Consumer Directed Personal Assistance Program (CDPAP)
  • Adult-day health care (i.e., medical model and social adult-day care)
  • Personal Emergency Response System (PERS)
  • Nutrition (i.e., home-delivered meals or congregate meals)
  • Home modifications
  • Medical equipment such as wheelchairs, medical supplies, prostheses, orthotics, and respiratory therapy
  • Physical, speech, and occupational therapy outside the home
  • Hearing aids and eyeglasses
  • Podiatry
  • Audiology, including hearing aids and batteries
  • Dental and optometry
  • Prescription drugs
  • Non-emergency medical transportation to doctors’ offices and clinics (i.e., ambulette)
  • Nursing-home care (covered by MLTC, but institutional budgeting and transfer-penalty rules apply).
Individual plans may cover additional services. It is imperative that a plan participant understand that the plan will not pay for these additional services if the provider is not in the plan or a referral from a plan provider is not obtained.

Federal law requires that the plans make services available to the same extent they are available to recipients of the former fee for-service Medicaid, PACE, or Medicaid Advantage Plus plans.

The plans may not define covered services more narrowly than the Medicaid program. Significantly, personal-care services including those from 24-hour sleep-in to split-shift services are available!

Services Not Covered
Services not covered by partially-capitated plans include the consumer’s primary care physician and other primary and acute medical care, including all doctors, all hospital inpatient and outpatient care, outpatient clinics, emergency-room care, and mental-health care. Also not covered are laboratory and radiology tests and prescription drugs. Such services are covered by Medicare.

Disenrollment
A member of a partially-capitated plan may disenroll at any time, for any reason, upon oral or written notice to the plan. Disenrollment will take effect the first day of the next month.  However, if the individual enrolls in a new plan after the third Friday of the month, the move to the new plan will not be effective until the second month.  The individual will have to stay with his or her current plan until then.

Aid Continuing
Before an MLTC plan reduces or terminates services that were previously authorized either by the plan or that the individual received before mandatory enrollment, the plan member is entitled to a hearing. The State must ensure the plan member’s due process right to continue receiving services unchanged (“aid continuing”), pending that hearing.

Plan members may pay their excess monthly income into the plan or they may conserve their excess income using a pooled-income trust.

The Consumer Directed Personal Assistance Program is available through the MLTC plans as it was under the former Medicaid home-care program.

In conclusion, as the transition from the Medicaid home-care program to MLTC continues to unfold, please share with us your specific concerns, thoughts and suggestions regarding meeting the needs of older adults and the disabled by writing in your impressions to mbpetroff@petroffelderlaw.com .

 
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