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MLTC Roll-Out - 2014 Expansion Schedule to ALL Upstate Counties

15 Apr, 2014

State Complaint Number for MLTC Problems - 1-866-712-7197 

  • e-mail mltcworkgroup@health.state.ny.us and put "COMPLAINT" in subject line
  • For enrollment complaints - call NY Medicaid Choice -
    • 1-855-886-0570 (Advocates line)
    •  1-888-401-6582 (Consumers line) 

New in April 2014

  • FOUR NEW COUNTIES start mandatory enrollment -- Columbia, Putnam, Sullivan, Ulster   THis week - week of April 15th  adult dual eligibles  receiving Medicaid personal care, private duty nursing, consumer directed personal assistance, certified home health aide care, adult day health care and Lombardi services began receiving the:
  1. "Announcement" letter from the State Dept. of Health that explains the changes, but does NOT YET  require the individual to join a plan. See also Spanish version -- Aviso importante de Medicaid  
  2. 60-Day Choice letter - In early May, they will receive a letter from NY Medicaid Choice will be mailed (MAXIMUS)--Form Letter to Personal Care/Home Attendant recipients  -- the enrollment broker under contract with the State Dept. of Health, requiring them to join an MLTC plan (or PACE or Medicaid Advantage Plus) within 60 days, or they will be randomly assigned to an MLTC plan.  The letter will include:
    •  Guide to MLTC, and
    • List of plans by County and Type of Plan (Updated March 2014)-   eventually you can download the list for each region at this link under "Long Term Care plans' by region  - but not posted yet for this region.  Full contact list available here.  Here are the plans available in the 4 new counties with enrollment as of Feb. 2014.  A blank space means





No. enrolled as of Feb. 2014 62 34 15 36


x x x x


x x x x




x x






  •            The "front door" closes in these counties on APRIL 21st, meaning the local Dept. of Social Services will no longer accept requests for personal care or CDPAP services, and enrollment in an MLTC plan is required for any of the other community-based long term care services. 

  • Mandatory enrollment of nursing home residents in MLTC and mainstream Managed Care plans still has not been approved by CMS as of April 15, 2014, but is still on track to be implemented June 1, 2014.  SEe more in this article.

New in January 2014

While mandatory enrollment is moving forward in 4 new upstate counties in January (Albany, Erie, Onondoga and Monroe - see more below) the State has released the proposed roll-out schedule for mandatory MLTC enrollment in upstate counties  during 2014, subject to approval by CMS.  Schedule officially published in GIS MA 2014/04 (Feb. 3, 2014):

April 1        Columbia, Putnam, Sullivan, Ulster - See update above under April 2014

May 1         Rensselaer, Cayuga, Herkimer, Oneida

June 1        Greene, Schenectady, Washington, Saratoga

July 1         Dutchess, Montgomery, Broome, Fulton, Madison, Schoharie, Oswego

August 1     Warren, Delaware, Niagara, Otsego, Chenango

September 1  Essex, Clinton, Franklin, Hamilton

October 1    Jefferson, Lewis, St. Lawrence, Steuben, Chautauqua, Cattaraugus, Alleghany

November    Yates, Seneca, Schuyler, Tioga, Cortland, Chemung

December    Genesee, Ontario, Livingston, Orleans, Tompkins, Wayne, Wyoming

To see what plan choices exist now in these counties, including MLTC, PACE, and MLTC plans, see this Statewide chart   (showing enrollment as of March 2014) see also this chart organized by insurance company, which sponsors the plan, showing which different MLTC/MAP/PACE plans are offered by the company as of Dec. 2013.  Shows which companies are launching FIDA plans in 2014.  Presumably more plans will be announced in the next months.

New in December 2013

  • First letters sent out for mandatory enrollment in FOUR Upstate Counties -- Albany, Erie, Onondoga and Monroe.   CMS approved extension of mandatory enrollment to cover the larger metropolitan areas of Syracuse, Buffalo, Rochester, and Albany.  On some yet unspecified date on or after December 1st, the "front door" will close in these counties for Medicaid community-based long term care services. 
    • FOR NEW APPLICANTS -- This means that a Medicaid recipieint who wants to apply for Medicaid personal care, CDPAP, medical adult day care, or private duty nursing services will have to enroll in a Managed Long Term Care, PACE, or Medicaid Advantage Plus (MAP) plan to receive these services, and can no longer apply to the local Medicaid program for them. 
    • CURRENT RECIPIENTS already receiving Medicaid personal care, CDPAP, medical adult day care, private duty nursing, long-term Certified home health agency (CHHA) care, or Lombardi services in those counties --  have already received the first of TWO letters:
      1. "Announcement" letter from the State Dept. of Health that explains the changes, but does NOT YET  require the individual to join a plan. See also Spanish version -- Aviso importante de Medicaid  
      2. 60-Day Choice letter - About 15-30 days after receiving that letter,  a letter from NY Medicaid Choice (MAXIMUS)--Form Letter to Personal Care/Home Attendant recipients  -- the enrollment broker under contract with the State Dept. of Health, requiring them to join an MLTC plan (or PACE or Medicaid Advantage Plus) within 60 days, or they will be randomly assigned to an MLTC plan.  The letter will include:
        •  Guide to MLTC
        • CONTACT LIST  for plansYou can download the same regional list from the NY Medicaid Choice website.  http://nymedicaidchoice.com/program-materials. -- Look only at the LONG TERM CARE PLANS not the "Health Plans" which are for people who do not have Medicare and are not MLTC plans.  Here are the new county lists
      3. Other Lists of plans by county - compiled by NYLAG, showing numbers enrolled as of Nov. 2013.  Includes PACE and Medicaid Advantage Plus (MAP) plans
      4. Statewide Plan contact list (NYS DOH site)
  • See more about the different types of plans, enrollment procedures and consumer protections in this article
  • See Tools for selecting an MLTC plan
  • See grievance and appeal rights  and appeal contacts

New in November 2013

New in September -October 2013

Orange and Rockland Counties - Start Mandatory MLTC Enrollment

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

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

Spousal Impoverishment Protections Extended to Managed Long Term Care Programs

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

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

New in August 2013


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

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

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

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

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


On August 26, 2013, CMS approved a "Memorandum of Understanding" (MOU) between NYS and DOH to launch a demonstration program by which "dual eligibles" - people who have both Medicare and Medicaid - will enroll in managed care plans that cover not only Medicaid long-term care services, as MLTC plans do, but also cover ALL other medical care covered by Medicare and Medicaid.  In other words, a FIDA member will essentially trade in ALL of their insurance cards -- Medicare, Medicaid, MLTC, Medigap, and Medicare Part D -- and only have one health plan -- their FIDA plan.

 As a demonstration program, NYS is targeting a smaller group of dual eligibles, not the whole state.  Not coincidentally, the target group are the SAME PEOPLE who were required to enroll in MLTC plans - those adults age 21+  who need community-based long term care services, who have Medicare and Medicaid, and who live in certain areas - NYC, Long Island, and Westchester.  People in the OPWDD and TBI waivers will be exempt, but people in the Nursing Home Transition & DIversion Waiver will be in the demonstration.  People living in nursing homes will also be in the demonstration, but on a different timeline.

Passive Enrollment and Opting Out-- Unlike MLTC, enrollment in a FIDA plan is not "mandatory."   MLTC members may choose to stay in an MLTC plan and use their Original Medicare or Medicare Advantage cards for their primary medical care.  However, FIDA will use a "passive enrollment" with the right to "opt-out."  In July 2014, MLTC members will receive notice that they may "voluntarily" enroll in a FIDA plan (and will be heavily marketed by their MLTC plans to join the one sponsored by the same company that sponsors the MLTC plan).   If they don't join a plan "voluntarily," and do not affirmatively OPT OUT prior to Oct. 1, 2014,  they will be "passively enrolled" into a plan effective Oct. 1, 2014.  They will have the right to disenroll after that date at any time, but since enrollment is by the month, there may be a delay in which they will not have access to their preferred doctors and other providers, if they are not in the FIDA plan's network.  People in nursing homes will have the same passive enrollment process, but a few months behind those in MLTC plans. 

More information will be posted on this website.  For now, see these resources:

New in June 2013

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

New in May 2013

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


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

UPDATE on LOMBARDI program - transition to MLTC

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

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

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

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

Transition Period Extension & Barriers to Enrollment --

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

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

Social Adult Day Care Update --

Also on May 8, 2013, DOH released  MLTC Policy 13.11: Social Day Care Services Q&A  and Letter from State Medicaid Director Helgerson to MLTC Plans on SADC  

which answers questions arising from the bribery scandal in which a NYS Assemblyman was arrested for allegedly taking a bribe from an operator of a social adult day care center -- the investigation surrounding this arrest eventually led to the suspension of the VNS NY Choice and VNS NY Medicaid Advantage Plus plans -- see links to press articles below in APRIL 2013 NEWS in this article.  The May 2013 Q&A references the Letter sent by the state Director of Medicaid, Jason Helgerson, to MLTC Plans on April 26, 2013. and supplements an earlier February 28, 2013 Directive -- MLTC Policy 13.05: Social Daycare Services Q&A

New State Webpage on MLTC Guidance -

A new State webpage that collects MLTC guidance, contracts, etc. --
MRT 90: Mandatory Enrollment Managed Long Term Care.  That link is one of many links to separate pages on the various MRT proposals Supplemental Information on Specific MRT Proposals

New in April 2013:

State Suspends Enrollment in VNS Choice MLTC and Medicaid Advantage Plus plans pending Investigation on Irregularities in enrollment in Social Adult Day Care program  

On Wednesday night, April 24, 2013, the State Dept. of Health suspended enrollment  statewide in VNSNY's two plans - VNS CHOICE, the largest MLTC plan in the state, and VNS Choice Plus, its "Medicaid Advantage Plus" plan.   The suspension is of all enrollment and marketing activites pending investigation of deficiencies.   As reported in the New York Times on April 26, 2013, the 20 MLTC plans in NYC acknowledged that in the last six months, over 3,316 people have newly enrolled in MLTC plans as a result of referrals from the new "pop-up" social adult day care centers, that are recruiting members from regular city-funded senior centers with promises of cash gifts and casino trips.  These new members are attractive to the MLTC plans since Medicaid pays the plans the same monthly premium, or capitation rate, for all members -- whether they need extensive long term care services because of severe disabilities, or minimal services.  However, it is suspected that many of these recruits need NO long term care services so should not be enrolled.   Advocates are concerned that plans "cherry pick" low-need people and avoid and discourage high-need people from enrolling.    By recruiting members who need little or no long-term care, these pop up day care  centers win the favor of managed long term care plans they contract with. 

Here is the Letter sent by the state Director of Medicaid, Jason Helgerson, to MLTC Plans on April 26, 2013.  

Here is the directive NYS DOH sent to local Medicaid programs statewide today April 26, 2013

"The Department of Health has notified VNS Choice MLTC and VNS Choice Total (MAP) that it must cease enrollment and marketing activities effective immediately. Enrollments that have been submitted and processed as of yesterday will remain valid.

This notification is being sent to all Local Department of Social Services for which VNS Choice MLTC and/or VNS Choice Total (MAP) has been authorized to provide service. Districts which are seeing active enrollments should take appropriate steps to advise VNS of any rejections of enrollments submitted after this notification. Please advise this office if there are any continued enrollment attempts by VNS Choice or VNS Choice Total.

Districts in which VNS Choice has been approved to begin operations, but is not actively processing enrollments, are included on this notification as the plan should not engage in any marketing activities.

If you have any questions or concerns please contact the Bureau of Managed Long Term Care at (518) 474-6965."

April 26, 2013 -  Letter sent by the state Director of Medicaid, Jason Helgerson, to MLTC Plans on April 26, 2013.  

May 8, 2013 - DOH released  MLTC Policy 13.11: Social Day Care Services Q&A  and Letter from State Medicaid Director Helgerson to MLTC Plans on SADC  which answers questions arising from the bribery scandal in which a NYS Assemblyman was arrested for allegedly taking a bribe from an operator of a social adult day care center -- the investigation surrounding this arrest eventually led to the suspension of the VNS NY Choice and VNS NY Medicaid Advantage Plus plans -- see links to press articles below in APRIL 2013 NEWS in this article.  The May 2013 Q&A references the Letter sent by the state Director of Medicaid, Jason Helgerson, to MLTC Plans on April 26, 2013. and supplements an earlier February 28, 2013 Directive -- MLTC Policy 13.05: Social Daycare Services Q&A

The state's investigation was triggered by arrest of a State Assemblyman from the Bronx for bribery by an operator of a center.. Previous press includes:

  • NY TImes April 4, 2013 - Assemblyman Eric Stevenson Is Accused of Taking Bribes
  • WNYC April 8, 2013 - Adult Day Cares too easy to open, Advocates Warn
  • Crain's Business April 8, 2013 - Bribery charge spotlights adult day care-- New York's move to mandatory managed long-term care has created demand for the kind of social services that prosecutors say led businessmen to seek special treatment from Bronx Assemblyman Eric Stevenson.
  • WNYC, August 17, 2013 Adult Daycares: Unregulated and High Profit
  • NY Times April 23, 2013 Day Centers Sprout Up, Luring Fit Elders and Costing Medicaid
  • Slate, April 23, 2013 Promise and Peril of Managed Care for Medicaid 
  • NY Daily News, April 24, 2013  Bronx adult day care center tied to Assemblyman Stevenson bribery scandal shuts its doors
  • Crain's Health Plus, April 24, 2013 (available thru subscription only.. copied below) Helgerson reacts to social day-care referrals
                Medicaid Director Jason Helgerson summoned all Medicaid managed long-term care plans to an urgent mandatory 10:30 conference call yesterday morning. He referenced a New York Times article that suggested the plans were getting new members from social adult day-care centers, and then immediately demanded data from the plans.   "Jason sounded extremely on edge," said one person who listened in on the 20-minute call.  Mr. Helgerson wanted all the plans to report by noon how many members they had in R&G Social Adult Day Care Center, a Bensonhurst, Brooklyn, site the article accused of luring in clients with cash and other gifts.
                Mr. Helgerson wanted the LTC plans to report back by 3 that afternoon with their semi-annual assessment of members, or SAAM, scores. SAAM gauges the ability of Medicaid recipients to perform activities of daily living.  Mr. Helgerson was looking for clues about whether people attending social adult day care centers who were enrolled in Medicaid LTC really didn't need the service. He suggested that referrals from the centers to LTC plans would violate Stark laws, and the state would halt enrollment at any health plan that took those referrals.
    "What is really annoying is that a lot of plans have been complaining to the state that social adult day-care programs have been popping up," says the source. "But it is a mandated service for LTC, and the state has wanted continuity of care for clients who were already enrolled in adult day care."
          While the state and the executive branch have not curtailed social adult day care, several politicians already had introduced bills that would have required social adult day-care programs to meet all the requirements of the New York State Office for the Aging. Currently, only the centers that get funding from the agency must meet those standards.
  • New York Times, June 6, 2013  Council Bill Would Crack Down on Proliferation of Adult Day Care Centers

Lombardi Program Participants in Mandatory MLTC Counties Required to Join MLTC or Medicaid Managed Care plans.

During the week of April  8, 2013 and continuing through April, the first "announcement: letters began going out to over 14,000 current Lombardi program participants in the mandatory counties - New York City, Nassau, Suffolk and Westchester, telling them that they will have to enroll in a Managed Long Term Care Plan.  In May, the same individuals will be sent a more formal letter giving them 60 days to select a plan.  (Exact letters not available but  similar to the ones sent to personal care recipients - click here).
On April 1, 2013, the federal CMS agency approved NYS's request to expand the requirement that adults needing community-based long term care enroll in managed long term care (MLTC) plans.  CMS approved the  amendment to the  1115 waiver (Partnership Plan and FSHRP). With this approval, the state will start to move the adult Lombardi (long term home health care) waiver population into Managed Long Term Care and Mainstream Managed Care plans. For dual eligibles over 21 in NYC, Nassau, Suffolk and Westchester Counties , the transition activities into MLTC will start this month.  For Medicaid-only recipients of Lombardi,  the transition into Mainstream Medicaid Managed Care plans  will occur statewide and will start this month as well.   
See Federal Approval letters for Long Term Home Health Care Program (LTHHCP) into Managed Long Term Care (MLTC) and Medicaid managed care (MMC)

See list of Lombardi programs in NYS (Feb. 2012) 

New in February 2013:

CONTINUITY OF CARE POLICY EXTENDED thru Dec. 31, 2013 in NYC and expanded to Westchester, Suffolk, and Nassau Counties

On Feb. 27, 2013, State Doh issued this directive extending the "Continuity of Care" policy from March 31, 2013 to Dec. 31, 2013, and for the first time, establishing this policy in Westchester, Nassau and Suffolk Counties.  

This means that MLTC plans in NYC and these counties must contract with any home care vendor that currently contracts with NYC HRA or the DSS agencies in these counties, as long as these vendor home care agencies are willing to accept the same rate paid in July 2012.  This policy is intended to promote continuity of care so that consumers can retain their longtime aides.  This continuity is threatened by the transition to MLTC since consumers could otherwise be assigned to MLTC plans that do not contract with the home care agencies that employ their longtime aides.  Also, MLTC plans will likely try to reduce the rates paid to the home care agencies that join their networks, threatening reductions in wages and benefits to aides.  

The directive also reminds plans of a different transition benefit, which requires plans to continue the same hours of care that the local DSS/HRA authorized for 60 days after enrollment in the MLTC plan.  For more info on that see next section in this announcement below.  


MLTC Policy 13.01 REVISED: Transition of Care for Fee for Services Participants in Mandatory Counties dated Feb. 6, 2013 --  further clarifies a previous   Jan. 17, 2013 Directive  -

Both the Jan. 17th and Feb. 6th directives remind MLTC plans that they are required to continue previously authorized long-term care services unchanged for 60 days when a consumer initially transfers into MLTC plans. This is called the Transition Period, required in the CMS Special Terms and Conditions approving the MLTC Waiver. p. 17 par. 28(d).  These directives remind plans of their obligation to provide notice before reducing services at the end of the 60-day transition period.  They must continue services unchanged during the internal appeal and until a hearing is decided, known as “Aid Continuing,” when a member appeals the plan's proposed reduction e or terminate a service.  

The directive states: 

This means that, for any individual receiving fee for service Medicaid community based long term
services and supports and enrolling under any circumstance, the plan must provide 60 days of continuity
of care. Further, if there is an appeal or fair hearing as a result of any proposed Plan reduction,
suspension, denial or termination of previously authorized services, the Plan must comply with the aid
to continue requirement identified above. In particular, if the enrollee requests a State fair hearing to
review a Plan adverse determination, aid-to-continue is to be provided until the fair hearing decision is
The revised directive of Feb. 6th clarifies that the requirement to continue past services unchanged for the first 60 days of MLTC enrollment applies to these services: 
  • Personal care (home attendant and housekeeping in NYC)
  • Consumer-Directed personal assistance (CDPAP)
  • Home Health (CHHA) services
  • Adult Day health Care
  • Private Duty Nursing

The revised directive of Feb. 6th also clarifies that the initial appeal of a proposed reduction in services is an INTERNAL APPEAL within the plan.  Only if that decision is adverse, in whole or in part, does the consumer have the right to request a FAIR HEARING.   

The revised directive of Feb. 6th includes a SAMPLE NOTICE to be used by MLTC plans  -- until now, the State had not issued any type of model notice, resulting in inconsistent and inadequate notices drafted by every plan.  

AID CONTINUING --  The plan must give “Aid Continuing” if the consumer TIM

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