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MLTC Roll-Out – Conflict-Free Assessment Begins October, New MLTC Counties, Delayed NH Roll-out
08 Oct, 2014
State Complaint Number for MLTC Problems - 1-866-712-7197
State Webpage on MLTC Policy -- MRT 90: Mandatory Enrollment Managed Long Term Care
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.
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:
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):
DOH has rolled out mandatory MLTC in additional counties. Here is the updated timeline:
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
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
You can also view and listen to a recording of the entire webinar at this link:
The PowerPoint and Appendix used in the webinar are available at the following links:
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
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
NEXT UP - FULLY INTEGRATED DUAL ADVANTAGE - FIDA -
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.
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.
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:
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 -
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, D