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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 

  • 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) 

State Webpage on MLTC Policy -- MRT 90: Mandatory Enrollment Managed Long Term Care

New in September - October 2014

  • OCTOBER 1, 2014 - Conflict-Free Evaluation and Enrollment Center (CFEEC) OPENS in MANHATTAN AND BRONX

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:

  • 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):

DOH has rolled out mandatory MLTC in additional counties.  Here is the updated timeline:

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

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
November 2014 Chenango, Cortland, Livingston, Ontario, Steuben, Tioga,  Tompkins, Wayne
December 2014 Genesee, Orleans, Otsego, Wyoming
January 2015 Chautauqua, Chemung, Seneca, Schuyler, Yates, Allegany, Cattaraugus
February 2015 Clinton, Essex, Franklin, Hamilton, Jefferson, Lewis, St. Lawrence

Source:   NYS DOH  Updated 2014-2015 MLTC Transition Timeline (PDF, 88KB)  (MRT e-mails)

  • 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 webinar are available at the following links:

PowerPoint: http://wnylc.com/health/download/474

Appendix: http://wnylc.com/health/download/473

  • 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:
      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, D

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