11202: Limit the Nursing Home Benefit in Partially Capitated MLTC Plans for Permanently Places Enrollees to Three Months

This law establishes a mandate that Partially Capitated MLTC plan enrollees who have been permanently placed in a nursing home for a period of three calendar months will be disenrolled from the plan and returned to fee for service Medicaid. There will be no impact to the member, who will remain in the same nursing home. The permanent placement designation is recognized as a mutual agreement between the enrollee, his or her physician, and the nursing home. The period of three months will commence once any available Medicare coverage has been maximized. This limitation only impacts the NH benefit for Partial Capitation plans. There is no impact to the nursing home benefit for MAP, PACE, FIDA, or Medicaid Managed Care.

New York has submitted a request to amend its Medicaid Redesign Team (MRT) demonstration, with the goal of the amendment being to limit the nursing home benefit in Managed Long Term Care Capitation Plans (MLTCP) to three months for enrollees who have been designated as permanently placed in a skilled nursing or residential health care facility (nursing home). After the three–month period, the beneficiary will be involuntarily disenrolled and coverage for nursing home services, in the same facility, will be covered by Medicaid fee–for–service—as long as the individual qualifies for institutional Medicaid coverage. The amendment also aligns the lock-in policy of MLTCP with Mainstream Managed Care Plans (MMCP). The federal public comment period will be open from September 26, 2018 through October 26, 2018.

To provide stakeholders additional time to comment on the proposed amendment, the Department is accepting comments for an additional thirty days or until November 23, 2018. Comments can be submitted via email to mltcinfo@health.ny.gov. In the subject line please indicate Proposed NH Benefit/Lock In 1115 Amendment Comments.