Plan Notice on Mandatory MLTC

September 20, 2012

Dear Managed Long Term Care Plan:

The New York State Department of Health (NYSDOH) has received written approval from the Centers for Medicare and Medicaid (CMS) to require certain Medicaid consumers to enroll in managed long term care plans. Throughout the approval process NYSDOH has partnered with stakeholders and New York Medicaid Choice to provide information and guidance on implementation protocols. The mandatory program began first in New York City, and we have concentrated educational efforts towards plans that operate within that service area. Implementation statewide will continue in accordance with the accepted transition plan.

As many plans operate in both the mandatory area and other districts, we would like to provide clarity on the statewide implications of a mandatory program.

The targeted audience for the mandatory initiative is the Dual Eligible (Medicare and Medicaid) consumer who is 21 or older, and requires more than 120 days of home and community based long term care services. Those services are defined as: home health care, personal care, private duty nursing, and Adult Day Health Care. On a Statewide basis this is now the eligibility standard for enrollment into a partially capitated MLTC plan.

In all districts, individuals between the ages of 18 and 20 may voluntarily enroll in a MLTC plan. The conditions of eligibility for this group are:

  1. requires more than 120 days of community based long term care services: and
  2. meet Nursing Home Level of Care criteria.

Non-dually eligible individuals, who are not otherwise considered mandatory for Mainstream Managed Care, may voluntarily enroll in a MLTC plan with the same eligibility conditions. Please note that the Program of all Inclusive Care for the Elderly (PACE) and the Medicaid Advantage Plus (MAP) plans are also subject to federal regulations which require that consumers meet Nursing Home Level of Care criteria, which remain in effect on a statewide basis.

It is our intention to communicate other changes that are a result of the standard terms and conditions (STC's) document that the state and federal government agreed to recently. I encourage you all to review that document which is available on the MRT website at the following link:

If you have any questions please contact me at (518) 402-5673 or your MLTC plan manager.


Mark Kissinger, Director
Division of Long Term Care
Office of Health Insurance Programs