Transition of Dual and Non-Dual Eligible LTHHCP

Participants to Managed Long Term Care (MLTC)/Mainstream Managed Care (MMC)

Mark Kissinger
Vallencia Lloyd
NYS DOH Office of Health Insurance Programs
March 18, 2013


Medicaid Redesign Team (MRT)

  • 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, New York Medicaid Choice.

MRT # 1458

  • Enroll additional populations into Medicaid Managed Care (MMC)
  • Additional benefits into the MMC benefit package
  • Phase in of populations and benefits over 3 year period
    • Benefits eg., pharmacy, orthodontia, personal care, PERS
    • Populations eg., HIV upstate, CIDP, Homeless, Consumer Directed.

CMS APPROVAL

  • On August 31, 2012, the Department received written approval from the Centers for Medicare and Medicaid Services (CMS) to move forward with the MRT 90 initiatives.
  • CMS approval is being granted in phases to fully implement MRT #1458 and transition/enrollment of individuals previously exempt or excluded from enrolling in Mainstream Managed Care and Managed Long Term Care Plans, including 1915(c) Long Term Home Health Care Program waiver participants.

MLTC Mandatory Target Population

The 2011 Budget legislation requires that all dual eligible (Medicaid and Medicare) 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.
  • LTHHCP waiver will remain operational for those participants not meeting the mandatory population definition and for participants for whom MLTC or other needed services are not yet available.

Amendment to the LTHHCP 1915 (c) Home and Community-Based Services Waiver

  • The amendment request was submitted to the Centers for Medicare and Medicaid Services (CMS) on July 2, 2012.
  • The LTHHCP 1915(c) amendment request is to align the approved waiver with the planned impact of the MMC/MLTC enrollment plan.
  • Request for Additional Information (RAI) received from CMS on August 30, 2012 and a response from NYS Department of Health was submitted on September 20, 2012.
  • Discussions with CMS are on-going.

MLTC Transition Activities - Duals

LTHHCP enrollment will cease upon CMS approval for those participants residing in NYC, Nassau, Suffolk and Westchester counties.

  • Approximately 17,600 LTHHCP participants are identified for initial transition:
    • NYC - 15,000
    • Nassau/Suffolk/Westchester - 2,600
  • Enrollment will continue statewide as MLTC capacity is developed.

MMC Transition Activities on-Duals

Upon CMS approval, non-duals will be transitioned on a state-wide basis

Approximately 3100 non-dual consumers are identified for transition.

400 children (under 18 years old)
2700 adults (aged 18 and older)

Approximately 62% are in NYC/38% rest of state

When MLTC Rollout Begins

  • New LTHHCP enrollment for dual eligible participants will cease in those initially designated areas.
  • Initial Client Notification Letter:
    • Informs the participant that the way home care services are received will soon change
    • That they will be required to join a MLTC plan or enroll in another program
    • Provides an informational booklet about managed care and a list of MLTC plans
    • Provides New York Medicaid Choice contact information

Types of MLTC Plans

Enrollees have a choice of three MLTC plans

  • Partially Capitated Managed LTC (Medicaid)
    Benefit package is long term care and ancillary services including home care and 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 specialized mental health services).

Additional MLTC Notification - Duals

  • Mandatory Notice - sixty day choice period begins with this notice.
  • Ten day outreach call.
  • Reminder Notices - thirty and forty-five day reminder letters will be sent to participants who are scheduled for transition that have not yet chosen a plan.
  • Auto Assignment:
    • If the consumer does not choose a plan within 60 days, one will be auto- assigned for them using the state´s approved algorithm.
    • A notice with the name of the plan and effective date will be sent to the participant.
  • Plan sends a welcome letter and membership card and will contact the member within 30 days.

When MMC Rollout Begins

Non-Duals

New LTHHCP enrollment for non-dual eligibles will cease.

Initial Client Notification Letter

  • Inform that the way services are received will soon change
  • Will need to enroll in a managed care plan
  • Informational booklet about managed care
  • New York Medicaid Choice contact information
  • Will be sent 30 days prior to mandatory notice and packet

Additional MMC Notification

  • Enrollment Packet
    • Informs LTHHCP participants that they have 60 days to choose a health Plan
    • Brochure
    • List of Managed Care Plans
    • Contact information for NY Medicaid Choice for information and assistance to enroll
    • Auto Assignment
      • If the consumer does not choose a plan within 60 days, one will be auto-assigned (AA) for them using the state´s approved AA algorithm.

Other Alternatives to MMC/MLTC Enrollment

Age 18 years and older -

  • Transition to Traumatic Brain Injury (TBI) or Nursing Home Transition & Diversion (NHTD) waiver
  • Developmental Disabled (DD) designation through OPWDD

Under 18 years -

  • Transition to Care at Home (CAH) I/II waiver
  • Developmentally Disabled (DD) designation through OPWDD

Mandated MMC Enrollment Exception

  • A 6 month exemption will be available for LTHHCP participants who choose to apply for another Medicaid waiver or developmental disability designation in the following situations:
    • Under 18 & in receipt of a waivered service NOT included in the MMC benefit package
    • 18 and over & no MLTC available in their county & in receipt of a waivered service NOT included in the MMC benefit package
    • If 18 and older and in receipt of Spousal Impoverishment Budgeting for MA eligibility & no MLTC available in their county

Six month exemption will not apply in all scenarios

  • The 6 month exemption will not apply in the following cases for the reason stated:
    • LTHHCP (non-dual) participants age 18 and over who live in a county without MLTC capacity and whose only waiver services are Medical Social Services and/or Home Delivered Meals waiver services. Services will be available them with enrollment in Mainstream Managed Care.
    • LTHHCP (non-dual) participants under age 18, whose only waiver services are Medical Social Services and/or Home Delivered Meals. Both will be available through the Plan.

How Can Providers Assist Consumers in Selecting the Right Plan?

  • Assist client in choice of MMC/MLTC Plan through identification of which Plans are contracted with the client´s current service providers.
  • Refer client to NY Medicaid Choice when necessary.
  • Work with client and family or other informal supports, the LDSS, and the Plan to coordinate the transition to MMC/MLTC.

Continuity of Care

  • The LTHHCP agency must provide the plan with the current Plan of Care (POC) to promote continuity and obtain authorization.
  • Pre-existing LTHHCP service plan will continue for at least 60 days after effective date of MMC/MLTC enrollment or until Plan´s assessment - whichever is later.
  • MCOs are strongly encouraged to maintain worker/client relationships.
  • MCO´s will be required to reimburse the LTHHCP at the FFS rate during the transition period.
  • Service providers will remain the same throughout transition period - no changes.

After 60 days or Plan´s assessment

  • The Plan will assume full responsibility for care management and provision of services.
  • Service providers must be contracted by the Plan to provide services after the transition period.
  • The LTHHCP agency may continue to service Plan members if appropriately contracted to do so.

Enrollee Rights

  • Member can file a complaint or grievance with the plan, either verbally or in writing.
  • Member can file an appeal for reconsideration of a plan decision, there are 2 types of appeals:
    • Expedited Appeal - determined within 3 business days. The plan must notify member of the determination by phone, written notification follows.
    • Standard Appeal - determined to within 30 days. The plan must send written notice to the member within 2 business days of the determination.
    • Review of appeal may be extended for up to 14 days for more information.
  • Member can file a Fair Hearing through the Office of Temporary and Disability Assistance (OTDA) either verbally or in writing and request Aid to Continue in certain situations.
  • Member can file an External Appeal with Department of Financial Services, when service denied for lack of medical necessity.
  • Member can file complaint with the Department of Health.

MLTC Lock-In Policy

  • If enrolled into a MLTC plan, individuals will not be subject to a Lock-In Period.
  • Once enrolled, the participant may request to change plans at any time by contacting the plan they want to join or by contacting NY Medicaid Choice at 1-888-401-6582.

MMC Lock-In Policy

  • If enrolled into a mainstream managed care plan, individuals will be subject to a twelve (12) month Lock-In Period following the Effective Date of Enrollment, with an initial ninety (90) day grace period in which to disenroll without cause and enroll in another health Plan, if available.
  • An enrollee with HIV or AIDS may request transfer from a managed care Plan to an HIV SNP, or from an HIV SNP to another HIV SNP at any time.

Mainstream Managed Care Benefit Package

  • Medicaid Managed Care enrollees are entitled to all Medicaid benefits
  • Recently added benefits include:
    • Dental, Orthodontia
    • Consumer Directed Personal Care Services (CDPAS)
    • Personal Emergency Response Systems (PERS)
    • Pharmacy & Medical/Surgical Supplies
    • Personal Care Services

New Benefits in MMC for Population

  • Medical Social Services and Home Delivered Meals are highly utilized but were not previously available in the Medicaid Managed Care benefit package.
  • Both services will be added to the MCO benefit package and will be available to transitioned LTHHCP participants who were in receipt of the service immediately prior to transition.
  • The waiver services will be available as long as there is assessed need.

Questions?