UPDATE ON THE TRANSITION OF FFS COMMUNITY BASED LTC SERVICES TO MLTC MODEL
- Presentation is also available in Portable Document Format (PDF)
Margaret O. Willard
mow01@health.state.ny.us
NYS Department of Health
NYPWA Winter Conference 2013
Medicaid Redesign Team (MRT) #90
- Established by Governor Cuomo in January 2011, the Medicaid Redesign Team brought together stakeholders and experts from throughout the state to work cooperatively on reforming New York State´s health care system and improve the provision of care.
- MRT 90 focuses on the transition of long–term community–based services into managed long–term care models.
- In order to achieve this goal, strong partnerships have been forged between stakeholders, the Department of Health, NYC/HRA and the enrollment broker, NY MA Choice.
CMS APPROVAL
- On August 31, 2012, the Department received written approval from CMS to move forward with MRT #90 Initiative
- Approval was granted to fully implement the transition and enrollment of individuals requiring community–based long–term care into Managed Long Term Care Plans or Care Coordination Models
MANDATORY INITIATIVE
- The definition of community–based long–term care services includes:
- Personal Care Services
- Home Health Services
- Adult Day Health Care
- Private Duty Nursing
MANDATORY ENROLLMENT
- Mandatory enrollment in New York City began September 19th when the door was closed to new Personal Care Services Program referrals
- All new cases are referred by HRA to one of the following programs based on need and preference: New York Medicaid Choice; LTHHCP; NHTD; or TBI waivers (if eligible)
MANDATORY TARGET POPULATION
Who needs to enroll?
The 2011 Budget legislation requires that all dual eligibles who are:
- Age 21 and older and in need of community–based long–term care Services for more than 120 days must enroll in a Managed Long Term Care Plan or other Care Coordination Model.
- Duals between 18 and 21 remain voluntary
VOLUNTARY POPULATIONS
In addition to those who must enroll in a Managed Long Term Care Plan or Care Coordination Model, the following individuals may voluntarily enroll:
- Dual eligible, 18–21 in need of community–based long–term care services for over 120 days.
- Non–dual eligibles, age 18 and older assessed as nursing home eligible.
TYPES OF PLANS
A prospective enrollee has a choice of three Managed Long Term Care Plans:
- Partially Capitated Managed LTC (Medicaid)
Benefit package is long–term care and ancillary services including home care, unlimited nursing home care - Program of All–Inclusive Care for the Elderly (PACE) (Medicare and Medicaid)
Benefit package includes all medically necessary services – primary, acute and long–term care - Medicaid Advantage Plus (MAP) (Medicare and Medicaid)
Benefit package includes primary, acute and long–term care services (excludes some specialized mental health services).
SERVICES INCLUDED
- Audiology
- Dental Services
- Home Care including Nursing, Home Health Aide, Occupational, Physical and Speech Therapies
- Home Delivery and/or Meals in a Group Setting
- Durable Medical Equipment
- Medical and Surgical Supplies
- Non–Emergency Transportation
- Nursing Home Care
- Nutrition and Nutritional Supplements
- Optometry/Eyeglasses
- Personal Care (such as assistance with bathing, eating, dressing, etc.)
- Personal Emergency Response Services
- Podiatry
- Private Duty Nursing
- Prosthesis and Orthotics
- Outpatient Rehabilitation Therapies
- Respiratory Therapy
CONSUMER OUTREACH & EDUCATION–Mandatory Program
- Announcement Notice
- Mandatory Notice
- 60–day choice period begins with this notice
- 10–day Outreach Call
- 30– day Reminder Notice
- 45–day Reminder Notice (with outreach call)
Notices are available in English, Spanish, Russian and Chinese.
IMPLEMENTATION
- Beginning September 17, 2012 any New York City dual eligible consumer, aged 21 and over, newly requiring community–based long–term care of 120 days must enroll in a Managed Long Term Care plan to receive these services.
- HRA is no longer accepting referrals for the PCSP or CDPAP. LTHHCP and waivers continue to be a choice for consumers.
EXEMPTIONS AND EXCLUSIONS
- Mandatory enrollees may request to be exempt or excluded from joining a MLTC plan due to a specific circumstance or unique health care need.
- Enrollment Broker´s (New York Medicaid Choice– NYMC) Client Service Representatives (CSRs) educate enrollees about the exemption and exclusion process; explain the specific criteria that must be met and send the exemption or exclusion packet when appropriate.
- Approved applications:
- Individual will remain on FFS Medicaid
- Individual is automatically disenrolled
- NYMC will send the individual notification
- Denied applications:
- Individual will receive a notice informing them of the denial and fair hearing options
ENROLLING IN A MLTC PLAN
- NYMC can only process enrollments into Partial Plans for individuals who received mandatory notices.
- Calls from individuals requesting enrollment into a MAP or PACE plan will be “warm transferred” to the plan of choice.
- Plans will submit electronic enrollments to NYMC.
- NYMC will send a confirmation notice to the enrollee once the enrollment is accepted.
ENROLLEES WHO REQUIRE PCS
- Once an enrollee has chosen a plan, that plan will be responsible for assessing the enrollee and determining their eligibility for community–based long–term care.
- After the enrollee has been assessed for services and has agreed to enroll in a specific MLTC plan (signed an enrollment form), the plan will send the enrollment electronically to New York Medicaid Choice.
- Enrollments received by the 20th of the month at noon will be effective the first of the following month.
- Enrollments received after the 20th at noon will be enrolled effective the 1st of the next month.
TRANSITION of UNDERCARE POPULATION
- June 2012: New York County began process (announcement letters followed w/in 30 days with mandatory notification then 60 days to select plan)/ All boroughs by November 2012 then continue
- January 2013: initiate enrollment of PCS, CDPAP and ADHC in Suffolk, Nassau and Westchester counties. Initiate enrollment of ADHC in NYC.
- CHHA and PDN to be transitioned in the near future
- LTHHCP to be transitioned upon approval of 1915c HCBS waiver
SERVICE PLAN WILL CONTINUE for 60 DAYS
If a reduction in hours is proposed before authorization ends, must issue a Notice of Action
- Enrollee has right to appeal rights with aid continuing
- Fair hearing rights if appeal is adverse to enrollee
ENROLLEE RIGHTS
- A member can file a complaint or grievance. This can be done verbally or in writing.
- A member can file an appeal for reconsideration of a decision. There are two types of appeals:
- Expedited Appeal – responded to within 72 hours by telephone, fax or other available method. Written notification follows.
- Standard Appeal – responded to within 14 days. The plan must send written notice to the member within two (2) business days of the determination.
- A member can file for a Fair Hearing. This can be done verbally or in writing. The target timeframe for fair hearing resolution should be within 60 days of the request for the hearing.
![](/health_care/medicaid/redesign/images/mltc_co_map.jpg)
MLTC ENROLLMENT
Statewide Enrollees in MLTC: 74,726 (As of 12/31/12)
- NYC: Partial Cap: 63,943, PACE 3131, Medicaid Advantage Plus: 2594 = 69,668
- ROS: Partial Cap: 3233, PACE 1463, Medicaid Advantage Plus: 362 = 5058
- TOTAL: Partial Cap: 67,176, PACE 4594, Medicaid Advantage Plus 2956 = 74,726
Number of Actively Enrolling Plans:
- Partial Caps: 22 (19 Serve NYC) PACE: 8 (2 Serve NYC) Medicaid Advantage Plus: 10 (10 Serve NYC)
MLTC APPLICATION STATUS
1/1/12 – 12/31/12
Under Review/Pending Approval | Approved | |
---|---|---|
Full Certificate of Authority | 30 (29 partial cap; 1 CCM) | 5 (all partial cap) |
Geographic Expansions (of currently operational plans) | 29 (21 partial cap; 4 PACE; 4 MAP) | 16 (13 partial cap; 1 PACE; 2 MAP) |
New Line of Business (added to a currently operational plan) | 9* (7 partial cap; 2 Medicaid Advantage Plus) *One plan is adding both a partial and a MAP |
6 (4 partial cap; 2 Medicaid Advantage Plus) |
NEXT PHASES
As plan capacity is established, dually eligible community–based long–term care service recipients will be enrolled as follows:
- Phase III: Rockland and Orange Counties – Anticipated June 2013.
- Phase IV: Albany, Erie, Onondaga and Monroe Counties
– Anticipated December 2013. - Phase V: Other counties with capacity – Anticipated June 2014
FINAL PHASE
Phase VI: Previously excluded dual eligible groups contingent upon development of appropriate programs:
- Nursing Home Transition and Diversion waiver participants
- Traumatic Brain Injury waiver participants
- Assisted Living Program participants
ROLE OF HRA
- HRA is working with DOH and the MLTC plans to help ensure a smooth transition of the personal care population to a MLTC plan.
- HRA will continue to retain responsibilities for all aspects of Medicaid eligibility and renewal for individuals enrolled in the Managed Long Term Care Program.
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