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MLTC Update - Guildnet stops new enrollment in 3 counties, Lawsuit on denials of increased hours, Rate cuts for CDPAP, new Immediate Needs procedure

30 Nov, 2016


  • State Complaint Number for MLTC Problems - 1-866-712-7197  or
  • Request Conflict-Free MLTC Assessment - needed to enroll in an MLTC plan 
  • FIDA - to OPT OUT call NY MEDICAID CHOICE at 1-855-600-3432  (1-855-600-FIDA)
    • Fax authorization to opt out someone else  1-917-228-8601

  • For MLTC enrollment complaints - call NY Medicaid Choice -
    •  1-855-886-0570 (Advocates line)     1-888-401-6582 (Consumers line)  
    •   also e-mail mltctac@health.ny.gov
  • ICAN - OMBUDSPROGRAM FOR FIDA & MLTC    Phone:  844-614-8800    

November 2016

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. 

According to public data on DOH website,   Guildnet has 40% of all 5,577 Suffolk MLTC members,  30% of all 6,159 Nassau MLTC members, and 15% of all Westchester MLTC members.  Guildnet ceasing new enrollments, especially in Long Island, will inevitably put pressure on other plans to fill the gap.  

North Shore LIJ
5 plans combined  - Centerlight, VNS Choice, Wellcare, Integra, Extended  
each 1 - 4 %
Total 9% 
TOTAL MLTC 5,577 100%
North Shore LIJ
VNS Choice

5 plans combined -Integra, Elderserve, Centerlight, Wellcare, Extended
each 1- 2%
Total 12%
TOTAL MLTC 6,159  100%

September - October 2016

  • Class action lawsuit filed by The Legal Aid Society, challenging the failure of MLTC plans run by Healthfirst (Senior Health Partners and Healthfirst Complete Care) to process requests for increases, and the arbitrary denial of requests for increases in hours where the requested care is medically necessary.   The lawsuit, called Bucceri et al. v. Zucker (No. 16 CV 8274 S.D.N.Y.), is against the company that operates Healthfirst and the NYS Dept. of Health.   See this article about the lawsuit.   This is the third lawsuit that challenges certain patterns of practices of MLTC plans. 

    • Caballero et al. v Zucker - Lawsuit brought by NYLAG against Healthfirst (including Senior Health Partners MLTC plan) challenging pattern of arbitrary reductions in hours without legally adequate notice or adequate justification for reducing hours that were previously determined to be medically necessary.  Proof of a medical improvement or other change in circumstances is required in such cases.  See info about case and July 20, 2016 New York Times article about case, Lives Upended by Disputed Cuts in Home-Health Care for Disabled Patients

    • Scofero v Zucker - Empire Justice Center filed this class action lawsuit against the New York State Department of Health (DOH) on behalf of elderly and disabled Medicaid beneficiaries in need of homecare services such as personal care aides.  The lawsuit challenges the pattern of MLTC plans turning away individuals with serious conditions who require significant amounts of homecare services.  The MLTC plans tell them that they won’t be able to offer the level of care they require, even though they are under contract with DOH to do so.  As a result, many individuals throughout New York State are left in nursing homes or are at risk of institutionalization.  According to the lawsuit, the failure of the state to provide these services to needy individuals violates both the federal Medicaid Act and the Americans with Disabilities Act.. Download Complaint here. 

  • IMMEDIATE NEED  - NYS Dept. of Health and NYC HRA issue new procedures to implement the expedite Immediate Need procedures for applying for Medicaid and personal care or CDPAP for those with Immediate Need for these services.  See this article.

  • RATE CUTS FOR CONSUMER DIRECTED PERSONAL ASSISTANCE (CDPAP) -Some MLTC plans have reduced the rates they pay to the vendors of their CDPAP services, called fiscal intermediaries. As a result, the wages of the CDPAP personal assistants have been cut.  This could lead to loss of valued longtime personal assistants.  Read about this on the website of the Consumer Directed Personal Assistance Association (CDPAANYS).  In October, CDPAANYS launched a survey for consumers to report how these cuts affect them.   

August 2016

The new expedited fast-track procedure for applying for Medicaid and obtaining personal care or CDPAP services where there is an "Immediate Need" through the LDSS goes into effect.   This procedure was required by a state law enacted to address the problem of delays in obtaining Medicaid and enrolling in an MLTC plan.  See this article about the law and how to do these applications. 

July 2016

Medicaid Matters NY, a statewide coalition, along with the New York Chapter of the National Academy of Elder Law Attorneys, issued a report titled "Mis-Managed Care: Fair Hearing Decisions on Medicaid Home Care Reductions by Managed Long Term Care Plans," to shed light on the findings of an extensive study of fair hearing decisions on reductions of personal care and Consumer Directed Personal Assistance services hours by Managed Long Term Care (MLTC) plans. The study identified all fair hearing decisions posted online during a seven-month period ending December 31, 2015. Decisions are posted in an online fair hearing archive of the state Office of Temporary & Disability Assistance (OTDA).  The report makes specific policy recommendations to address the need for better oversight and monitoring of plan activities.  The report was featured in a story in the NYTimes on July 21, 2016.

See the MMNY press release on the report here. Download the report on the NY Times site or the MMNY site.

January - February 2016

  • In April 2016, the Consumer-Directed (CDPAP) program will expand  to allow  parents of disabled adult children to serve as CDPAP aide if they are not also the recipient's designated representative.  This change was signed into law on November 20, 2015, amending Social Services Law §365-f, subd. 3.  See more in this article.  This change must be followed by MLTC plans, managed care plans and in the CDPAP program run by local Medicaid agencies for those who are not in managed care.

  • Funding the Cost of Increased Aide Wages with New Overtime Requirements -

On February 4, 2016,  the state Department of Health (DOH) announced that it will be advancing $22.8 million in state-share funds to MLTC plans, which must directly pass the funds through to  home care agencies they contract with, to meet their initial obligations under the recent Federal Labor Standards Act (FLSA) rule to pay aides overtime pay and travel between clients.    See more at this article by Home Care Association of NYS

  • Given that the Consumer-Directed Personal Assistance Association estimates that overtime costs for Consumer-Directed workers alone will cost $35 million in 2016-17, the announcement by the state is not likely to be adequate to fund the extra costs.  

  • Four trade associations representing providers estimate that the cost of the proposed increase in the minimum wage to $15, which will affect home care aides and other health workers, are requesting $916 million in appropriations to fund the first 2 years of increased costs for hospitals, nursing homes, and home care agencies.  See HCA web posting 2/4/16  and Letter to Governor Cuomo, dated Feb. 4, 2016.

  • Regulations Amended Defining Who is Eligible for 24-hour Live-in or Split-Shift Personal Care or CDPAP Services - 

The State Dept. of Health notified MLTC plans that they must comply with revised regulations that are used in assessing the need for Personal Care Services and CDPAP.   In particular, these changes modify who is eligible for 24-hour care, specify requirements for the content of notices when plans deny or reduce services, and make other changes.   For a full description of the changes for personal care, see this article.  The changes governing CDPAP are similar, and the article on CDPAP will be updated soon. 

MLTC Policy 15.09: Changes to the Regulations for Personal Care Services (PCS) and Consumer Directed Personal Assistance (CDPA)  Notice of Adoption (PDF, 1.8MB)

New in July - December 2015

  • "Front Door" Re-Opens to Request Personal Care or Consumer-Directed services from local Medicaid office while awaiting enrollment in MLTC plan  

In July 2015, NYS Dept. of Health issued GIS 15 MA/011 - Reminder of Expedited Authorization Process for Medicaid Recipients with Immediate Need for Personal Care Services -- PDF.   This directive makes an important change for any adult who has Medicare who needs Medicaid home care.  Before this directive was issued, the "front door" was closed  to request Medicaid personal care services from the local Medicaid agency.  Anyone who had Medicare had to apply for Medicaid at the local Medicaid agency, but then had to enroll in a Managed Long Term Care plan to get home care.  This caused big delays, described more here.  With this directive,  the individual may submit a physician's order - known as an M11q in New York City (fill-in-able version) - to the local Medicaid office, which must authorize personal care services if there is an "immediate need" for these services.  Also see Q-Tips for tips on how the physician can complete the M11q.

TIP:  Though this directive says that the local Medicaid agency will only process a request for expedited home care once Medicaid is approved, you can still submit the physician's order/ M11q along with the Medicaid application.   Include a cover letter that requests that the Medicaid application be expedited and explain why individual has an immediate need for services and cannot wait to enroll in an MLTC plan.    For more information see this article

  • Two MLTC plans pull out of MLTC program:

    • December 2015 - HIP/EmblemHealth MLTC plan sent letters to its 1300 members on November 25, 2015 that it would no longer offer MLTC coverage as of January 1, 2015.  The notice stated that unless members  choose and enroll in another MLTC plan by December 18th, they will automatically be  enrolled in Guildnet.   Emblemhealth had the 5th smallest  enrollment of the MLTC plans in NYC.  

    • September 2015 - Homefirst discontinued enrolling new members in eight upstate counties -- Albany, Erie, Niagara, Monroe, Onondaga, Rensselaer, Saratoga, and Schenectady.  Membership in this plan in these counties totaled 715, with Monroe County the most impacted.   Members were notified that they could switch to another plan, but remain in Homefirst if they did nothing.   Concerns about the plan pulling out include  that:
      • people who remained in the plan could face barriers in accessing services from a plan that was pulling out of that county.  

      •  As the policy is understood, members who switch plans are not entitled to the new plan continuing the same services  they had received from HomeFirst, because it is considered a "voluntary" move.   This is contrary to the usual 90 day "transition period" which anyone required to switch to MLTC is entitled to.  

      • Given the small number of plans in these upstate counties, there are also concerns that the other plans lack the resources to serve all of the enrolllees who transferred.

  • Oct. 13, 2015 - Overtime Rule for Home Care Aide Goes Into Effect 

  • October 13, 2015 -  Home Care aides entitled to overtime pay if work over 40 hours/week, with special rules for live-in cases.   This change arises from a change in the federal regulations implementing the Fair Labor Standards Act (FLSA), which for decades exempted home care workers from overtime requirements under a "companionship" exemption.  These regulations were amended, and then upheld by a federal court when challenged.   For aides whose employer assigns them to travel between two or more clients, their travel time for traveling from one client to another must be compensated and counts toward 40 hours.  

  • State clarifies procedures regarding conflict free assessment for people in nursing homes

New in June - July 2015

  • APPEALS - "Exhaustion" of Internal Appeal will no Longer be Required effective July 1, 2015.  This means member can immediately request a Fair Hearing to challenge a proposed denial, reduction or termination of services. While one may still request an internal appeal, one can only receive AID CONTINUING by requesting a Fair Hearing.  Read more about this change here.

  • Expansion of Conflict-Free Eligibility & Enrollment Center -- Now rolling out to final region (See chart).  In these counties, MUST REQUEST Conflict-Free assessment by NY Medicaid Choice before you may enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350.  See more here.    CFEEC rolled out from Oct. 2014 in NYC and by June 2015 was in effect throughout the State.

Region Month Counties
  1 October 2014 New York (Manhattan) & Bronx
 2 November 2014 Kings (Brooklyn), Queens, Nassau & Richmond (Staten Island)
 3 February 2015 Westchester & Suffolk
  4 March 2015 East Hudson (Columbia, Dutchess, Putnam),
Catskill (Rockland, Orange, Ulster, Greene, Sullivan),
Capital (Warren, Washington, Saratoga, Fulton, Montgomery,
Schoharie, Schenectady, Albany, Rensselaer),
& Other (Erie, Monroe, Onondaga)
  5 April 2015 Southern Tier (Tompkins, Cortland, Tioga, Broome, Chenango,
Otsego, Delaware), Finger Lakes (Wayne, Ontario, Livingston,
Cayuga, Steuben), & Western (Cattaraugus, Wyoming, Genesee,
Orleans, Niagara)
  6 May 2015 Central (Oswego, Oneida, Herkimer, Madison)
  7 June 2015 Early June (Chautauqua, Chemung, Essex, Hamilton, Schuyler, Seneca, Yates)
Late June (Allegany, St. Lawrence, Franklin, Clinton, Jefferson, Lewis) - Pending CMS Approval
  • Mandatory MLTC Expands in June 2015 to SEVEN NEW COUNTIES and in July 2015 to last SIX COUNTIES in State

Source:   NYS DOH  Updated 2014-2015 MLTC Transition Timeline (PDF, 88KB)  (MRT e-mails)  NYS DOH Policy & Planning Monthly Updates  (on file with EFLRP - contact eflrp@nylag.org)

Month New Schedule "MLTC Announcement" letter sent 60-day "Choice" letters sent "Front door" closed - no new Personal Care applications at local Medicaid office
9/2012 - 12/2013

NYC, Albany, Erie, Monroe, Nassau, Onondaga, Orange, Rockland, Suffolk, Westchester

Jan 2014 Columbia, Putnam, Sullivan, Ulster April 2014 early May 2014 May __  2014
June 2014 Cayuga, Herkimer, Oneida, and Rensselaer Week of May 23, 2014 week of June 2, 2014 May 30th
July 2014 Greene, Saratoga, Schenectady, and Washington Week of June 30th Week of July 14 July 7, 2014
August 2014 Dutchess, Montgomery, Broome, Fulton, Schoharie Week of Aug. 29th Week of Sept. 22nd September 8, 2014
September 2014 Delaware, Warren Sept. 15th Oct. 1st Sept. 22nd 
October 2014 Niagara, Madison, Oswego Week of Oct. 27, 2014 Oct. 20th
November 2014 Chenango, Cortland, Livingston, Ontario, Steuben, Tioga,  Tompkins, Wayne November 2014?
December 2014 Genesee, Orleans, Otsego, Wyoming Week of December 29, 2014 Jan. 5, 2015
March 2015 Cattaraugus March 2015 March 9, 2015
June 2015

Essex, Chemung, Chautauqua, Hamilton, Schuyler, Seneca, and Yates.

 June 2015 June 19, 2015 (on and after 6/22/2015 must enroll in MLTC)

July 2015

  Allegany,  Clinton, Franklin,   Jefferson, Lewis, St. Lawrence

July 3, 2015

New in March  2015

  • Conflict-Free Eligibility & Enrollment Center expands to more counties (see current chart in JUNE 2015 news) .  In there counties, MUST REQUEST Conflict-Free assessment by NY Medicaid Choice before you may enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350.  See more here.

  • Updated  roll- out of mandatory MLTC - updated timeline (see June 2015 update)

New in December 2014

  • On Dec. 19, CMS posted  New York Fully Integrated Duals Advantage (FIDA) Provider FAQs for providers and consumers
  • On Dec. 29, DOH announced tentative verbal approval by CMS of the Mandatory enrollment of Nursing Home Residents in Managed Care and MLTC plans --  to begin Feb. 1, 2015 in NYC (only for those who first become permanent nursing home residents after that date), and later outside NYC.  See this article for new scheduled dates. and for more information about this new expansion of MLTC and mainstream managed care.
  • See update on FIDA roll-out beginning this month, for enrollment beginning Jan. 2015

New in November 2014

  • POSTED 11/25/14 - Click here to download final version of "FIDA Announcement Notice" being sent by State Dept. of Health to over 110,000 MLTC members in NYC and Nassau County.  Letter being sent on a rolling basis in batches.  (This version includes attached list of FIDA plans for both NYC and Nassau County.  Client will only receive the one for their district.)     NOTE:  DOH failed to include crucial information - rejecting consumer advocacy, including:
    • Right to Opt Out of FIDA
    • Fact that you will be passively enrolled in FIDA if you don't opt out -- and when
    • Says FIDA is free but doesn't explain that you still owe Medicaid Spend-down, if you have one - a source of confusion
    • Nothing clarifying that must obtain all medical and long term care in-network from plan, ...
    • and more..  Compare final notice with edits proposed by consumers to earlier version of notice
    • POSTED DOCUMENT includes inserts about ICAN - the new OMBUDSPROGRAM and how to request info in other languages.
  • More info on how FIDA will roll out -

    • SEE NYLAG Fact Sheet on FIDA  with list of plans in NYC and Nassau County (Region I - first to roll out)

    • List of the 22 FIDA contracts is here published by Crain's NY.  Until now, State only released list of 25 plans being considered for FIDA,but not the final list of 22 plans.   Many plans are listed under different corporate names.   NYLAG has compiled a list of the 22 plans showing which MLTC and Medicaid Advantage Plus plans they are affiliated with in each county in the Demonstration area - NYC, Long Island and Westchester.  Note that some plans do not operate in every borough in NYC.

  • DOH Policy & Planning update dated Oct. 16, 2014  has important info: 
    • ROLL-OUT SCHEDULE - When MLTC recipients in Region I (NYC and Nassau) will receive the "announcement" letter starting December 2014 them telling about FIDA,  and when will they be passively enrolled into FIDA plans - will be on a rolling basis depending on when they renew Medicaid for the year.  Passive enrollment will happen over FOUR MONTHS beginning April 2015   Region II (Suffolk and Westchester) won't start receiving letters until March 2015.

    • NEWS that current NURSING HOME RESIDENTS will NOT be passively enrolled into FIDA plans!  Only NEW people who first become PERMANENT NH residents in 2015 will be passively enrolled but not til August 2015.  Only people who have approved for Institutional Medicaid after  the 5-year lookback has been  approved will be subject to passive enrollment.  They will first receive letters giving them at least 90 days to select a FIDA plan on their own or to OPT OUT, and only at the end will be passively enrolled.

  • NOV.1st -- Conflict-Free Assessment required before MLTC enrollment in Brooklyn, Queens, Staten Island and Nassau County.  See Sept. - Oct. 2014 news below.   Must call NY Medicaid Choice to request assessment before you can enroll in an MLTC plan, in all of NYC and Nassau County. To schedule an evaluation, call 855-222-8350.

  • Niagara, Madison, Oswego become mandatory for MLTC.  See chart below for all counties schedule.Front door closed for applying for personal care at local DSS on Oct. 20th.
  • State issues new directive on Spousal Impoverishment protections, rescinding August 2014 directive and reinstating earlier directives.  As a result, pooled trusts are again allowed for couples where one spouse is in MLTC.   This is temporary - awaiting clarification from CMS.   Suffolk County and  any other county must retroactively re-budget every client, again allowing the pooled trust.  See this article

New in September - October 2014

On Sept. 30, 2014, DOH issued MLTC Policy 14.06: Implementation of the Conflict-Free Evaluation and Enrollment Center (CFEEC)  that announces that the CFEEC is open in Manhattan and the Bronx.  Anyone approved for Medicaid after Oct. 1, 2014 in those boroughs who is seeking Managed Long Term Care will need to first contact NEW YORK MEDICAID CHOICE and request a CFEEC assessment.  If that assessment finds the person eligible for MLTC, then the person can enroll in an MLTC plan.  To schedule an evaluation, call 855-222-8350.

SEE NEW YORK MEDICAID CHOICE WEBSITE ON CFEEC - http://nymedicaidchoice.com/ask/conflict-free-evaluation-and-enrollment-center

This is being implemented pursuant to #28 of the Special Terms and Conditions, which is CMS's approval of the State's 1115 waiver to implement mandatory MLTC, DOH has established a conflict-free assessment system for all voluntary enrollments into MLTC, MAP and PACE effective October 1, 2014.

Currently, private MLTC plans are responsible for determining eligibility for Medicaid-covered long-term services and supports (LTSS).  This creates an intrinsic conflict of interest, because plans have a financial stake in avoiding high-cost members and attracting low-cost members.  To partially reduce this conflict, DOH will prohibit MLTC plans themselves from enrolling new members.  Instead, they will be required to refer prospective members to New York Medicaid Choice (aka Maximus), currently the enrollment broker for Medicaid managed care in NY.

Under this program, NY Medicaid Choice will establish a Conflict-Free Evaluation and Enrollment Center (CFEEC) to schedule and conduct initial assessment visits in the home or facility by a nurse (employed by or under contract with the CFEEC).  Using the Uniform Assessment Tool, the CFEEC makes the determination of eligibility for Medicaid LTSS.  If the CFEEC determines that the applicant is ineligible for Medicaid LTSS, it will send a written notice with appeal rights.  If the CFEEC approves the applicant, then any MLTC, MAP, PACE or FIDA plan must accept the applicant's enrollment.  If the plan disagrees with the CFEEC's determination of eligibility, it may pursue a dispute adjudication procedure via Maximus and DOH.

The CFEEC will be rolled out in phases:

  • Region 1 – October 2014: New York & Bronx
  • Region 2 – November 2014: Kings, Queens, Nassau, & Richmond
  • Region 3 – February 2015: Westchester & Suffolk
  • Region 4 - March 2015: Columbia, Dutchess, Putnam, Rockland, Orange, Ulster, Greene, Sullivan, Warren, Washington, Saratoga, Fulton, Montgomery, Schoharie, Schenectady, Albany, Rensselaer, Erie, Monroe, Onondaga
  • Region 5 – April 2015: Tompkins, Cortland, Tioga, Broome, Chenango, Otsego, Delaware, Wayne, Ontario, Livingston, Seneca, Cayuga, Yates, Schuyler, Chemung, Steuben, Chautauqua, Cattaraugus, Allegany, Wyoming, Genesee, Orleans, Niagara)
  • Region 6 – May 2015: Jefferson, Oswego, Lewis, Oneida, Herkimer, Madison, St. Lawrence, Franklin, Clinton, Essex, Hamilton)

Source: N.Y. Dep't of Health, FIDA and MLTC Policy and Planning Update Presentation (September 11, 2014, on file with NYLAG).

Will this delay enrollment into MLTC?  Probably.  MLTC plans may not accept an enrollment without confirmation from CFEEC that you are MLTC-eligible.  That confirmation is valid for 60  days.   The State FAQ (Q13) says the CFEEC assessment can be done while Medicaid application is pending, but since a Medicaid application can take more than 60 days - it can be risky.  It is also unclear whether the consumer must only sign an MLTC plan enrollment form within 60 days of the CFEEC assessment, or must actually be enrolled in the plan by that date - the difference can be significant.

See new documents available from NYS DOH on the Conflict-Free Evaluation and Enrollment Center (CFEEC):

  •   Mandatory MLTC/MMC for Nursing Home Residents Postponed Again

While we have no written confirmation of this fact, DOH staff have stated that the initiative to require all nursing home residents to enroll in Medicaid managed care plans has been once again postponed, this time to January 2015.  Further updates may be posted here. 

New in July 2014

  • Four more Upstate Counties Start Mandatory MLTC enrollment 

Greene, Saratoga, Schenectady, and Washington Counties --  The mailing of announcement notices to the fee for service population began  during the week of June 30th, and the mailing of mandatory letters began  during the week of July 14, 2014, giving 60-days to select a plan before being randomly assigned to an MLTC plan.

Beginning July 7, 2014, the "front door" is closed -- the County DSS no longer accepts applications for personal care or CDPAP.  Applicants for those services, who have obtained Medicaid by applying at their local DSS,  must select an MLTC plan, PACE or MAP plan -- and may enroll directly through the plan..    Contact New York Medicaid Choice  1-888-401-6582.

“The Office of Health Insurance Programs has not received approval from CMS to transition the Nursing Home benefit and population into managed care.  We continue to negotiate the terms of this transition and therefore the implementation date has been extended to August 1, 2014.  We will modify the current timeline reflected in the Nursing Home Policy Paper and will re-post it to the web.  We apologize if the delay causes any disruption and will inform you when the approval is obtained.”

In New York City, Long Island and Westchester County, mandatory enrollment in managed care for new, permanent residents has been postponed from March 1st to June 1 and now to August  1, 2014. Other areas of the state that were scheduled to make the transition six months later are presumably now scheduled to begin mandatory enrollment on Jan. 1, 2014,  The delay provides the state with additional time to address some of the concerns that LeadingAge NY and other associations have raised regarding the transition. On March 14, 2014, NYLAG and six other consumer advocacy organizations in NYS sent a letter to the federal Medicaid agency, CMS and to the State Dept. of  Health asking them to slow down the expansion of Medicaid managed care to include all new nursing home residents who become permanently placed in nursing homes after April 1, 2014

New in June 2014

Nursing Home Resident Transition to Managed Care Delayed One Month to July 2014 downstate, Dec. 14 upstate

According to a State DOH Alert  Leading Age NY web posting on June 3, 2014, the Department of Health has delayed for one month the mandatory enrollment in managed care plans of new, permanent nursing home residents on Medicaid.  The state has yet to receive approval from the Centers for Medicare and Medicaid Services for its plan to transition the nursing home population and benefit into Medicaid managed care.

New in May - April 2014

  • May 23, 2014 - FOUR MORE UPSTATE COUNTIES GOING MANDATORY -  From DOH:  "The Department has moved forward with next step in the transition of fee for service community based long term care services to Managed Long Term Care in Cayuga, Herkimer, Oneida, and Rensselaer Counties.  

    The mailing of announcement notices to the fee for service population began this week and the mailing of mandatory letters will begin during the week of June 2, 2014. 

    Beginning May 30, 2014, consumers seeking Community Based Long Term Care Services will be directed to New York Medicaid Choice for education of Managed Long Term Care options in their county. The number that should be used is 1-888 401-6582.

    The Department remains on track with the remainder of the planned transition, and we anticipate moving Greene, Saratoga, Schenectady, and Washington to mandatory MLTC during the month of June.

    Questions specific to the transition may be directed to MLTCTRANS@health.state.ny.us.

  • May 22, 2014 State posts directive requiring MLTC plans to assess potential enrollees who are in nursing homes - whether they are in nursing homes temporarily or permanently.   See  MLTC Policy 14.04: MLTCP Potential Enrollee Assessments ,  THe MLTC plan must conduct the assessment within 30 days of the referral.  The plan may also require an in-home assessment to make sure the home environment is safe, but may not require the prospective member to travel to their home for the assessment.  A family member or other person may give access. NYLAG, Disability Rights New York and other advocates pressed for this directive for over a year, since the MLTC plans' refusal to assess nursing home residents prevented them from returning to the community, violating their rights under the ADA and Olmstead.

  • May 5, 2014 - State issues directive that takes a step in fixing computer coding problems that delay enrollment in MLTC.  NYS DOH GIS 2014 MA/10 -- 06 to 30 Conversion for MLTC Enrollees.  An unexpected but serious problem with implementation of MLTC has been long delays in enrolling in an MLTC plan, even after an individual has endured the long process of applying for Medicaid.  Problems are especially bad for people who apply for Medicaid and are determined to have a spend-down or "excess income."  Their Medicaid coverage does not become effective until they submit medical bills that meet the spend-down, according to complicated rules explained here  and on the State's website.   Many people applying for Medicaid to pay for long-term care services can't activate their Medicaid coverage until they actually begin receiving the services, because they don't have enough other medical bills that meet their spend-down.  This creates a catch-22, because they cannot start receiving MLTC services until Medicaid is activated.  Until their Medicaid is activated, the Medicaid computer is coded to show they are not eligible.  As a result, an MLTC plan could refuse to enroll them -- because they do not have active Medicaid. To address this problem,  the State is trying a few steps.
    • First, applicants must request Eligibility CODE 06 if they are seeking MLTC.  See Medicaid Alert dated July 12, 2012. THis gives them "Provisional Medicaid" eligibility so that an MLTC plan sees they have Medicaid and will enroll them.
    • Second, until now, the MLTC plan had to then request that HRA/DSS "convert" their eligibility to CODE 30, which is full Medicaid rather than provisional Medicaid.   In NYC, MLTC plans were required to fax HRA a "conversion form and  package" to activate Medicaid when the consumer has a spend-down.  Download Conversion cover sheet here.  Despite extensive education by HRA, many plans failed to do this.
    • NOW, in May 2014, this new GIS explains that as long as CODE 06 was used on the application, the code will automatically change to CODE 30 full eligibility when the MLTC plan enrolls the individual.  So.. no "conversion" form should be necessary.
  • "Medicaid Shift Fuels Rush for Profitable Clients" - New York Times reporter Nina Bernstein uncovers disturbing behavior among the Managed Long Term Care plans early in the implementation of mandatory MLTC, as they competed for market share of new enrollees  (published May 9, 2014)

  • Webinar available for online viewing  explaining Managed Long Term Care and the upcoming expansion to require new nursing home residents to enroll in MLTC plans, or, for those without Medicare, into mainstream managed care plans.  The webinar was recorded April 24, 2014 and was conducted by Valerie Bogart and David Silva of the Evelyn Frank Legal REsources Program at NYLAG.

You can also view and listen to a recording of the entire webinar at this link:

https://attendee.gotowebinar.com/recording/1348252302283983105 (2.25 hours)

The PowerPoint and Appendix used in the w

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