NYS Medicaid Managed Long Term Care Guide (MLTC Guide)

Medicaid Redesign in New York State

  • Guide is also available in Portable Document Format (PDF)

Medicaid Managed Long Term Care

Your options for home care and other long–term care services

Medicaid Managed Long Term Care

Managed Long Term Care Plans help provide services and support to people with a long–lasting health problem or disability. These Plans are approved by the New York State Department of Health to provide Medicaid managed long term care.

A Plan can provide your Medicaid home care and other long–term care benefits. To get these services, you may be required to join a Plan.

This Guide tells you who must join a Plan, how the different Plans work, and other important things you should know. The Guide can also help you select a Plan.

New York Medicaid Choice – We can help

New York Medicaid Choice is a State program. Counselors will answer your questions and assist you over the phone or TTY. If you have trouble reading or understanding this Guide, we can help. We speak all languages.

New York Medicaid Choice 1–888–401–6582 or TTY: 1–888–329–1541 Monday to Friday, 8:30 am – 8:00 pm Saturday, 10:00 am – 6:00 pm

This Guide is available on CD and in Braille

Table of Contents

What is a Managed Long Term Care Plan?

  • What is a Plan?
  • Who Must Join a Plan?
  • I Get Home Care Now
  • How Long Do I Stay with a Plan?
  • What Services Will I Get from a Plan?

pages 4– 6

____________________________________________________

How to Choose A Plan

  • Pick the Type of Plan You Want
  • Fill out the Provider Worksheet
  • Enroll in Your Plan

pages 7–15

____________________________________________________

After You Join a Plan

  • Transitional Care
  • If you have Special Needs
  • Your Rights and Responsibilities
  • Changing Plans
  • Problem Solving

pages 16 – 20

____________________________________________________

Who Does Not Have to Join a Plan

pages 21– 22

What is a Managed Long Term Care Plan?

What is a Plan?

Each Plan has its own group of home care agencies, professionals and other providers. This group is the Plan’s network of providers. After you join a Plan, you must get your services from the Plan’s providers.

>You will have a person–centered Plan of Care, which means that you will have an active role in planning your services. You will have a Care Manager who will get to know you and talk with you about your service needs. Your Care Manager will assist you and anyone else you want to involve, in developing a Plan of Care that meets your specific needs.

There are three different types of Plans. You will learn about these Plans and how they work in the next section of this Guide.

■ MLTC Medicaid Plan

♦ Medicaid Advantage Plus

⚫ Program for All–Inclusive Care for the Elderly (PACE)

Who Must Join a Plan?

You must join a Plan if:

  • You have both Medicaid and Medicare
  • You need home care, adult day health care, or other long–term care for more than 120 days (four months)
  • You are age 21 or older.

I Get Home Care Now. Do I Have to Join a Plan?

Yes – you must join a Plan if you received a letter from New York Medicaid Choice telling you to join a Plan by a certain date. The Plan you select will take over your care and approve your services. If you do not select a Plan, the Medicaid Program will assign you to one of the MLTC Medicaid Plans in your borough or county.

How Long Do I Stay with a Plan?

A Plan must approve your services for as long as you qualify for home care and other long–term care services. You decide what Plan you want. You can also ask to change Plans at any time.

What Services Will I Get From a Plan?

All Plans provide Medicaid home care and other community long term care services. These are the services you are required to receive from a Plan.

Some Plans also provide Medicare services, including doctor office visits, hospital care, pharmacy and other health–related services. If you join a Plan that covers Medicare health services, you must get your care from the Plan’s doctors and other providers.

What services you will get from your Plan will depend on the type of Plan you select.

■
MLTC Medicaid Plan		 ♦
Medicaid Advantage Plus		 ⚫
PACE
Medicaid services Medicaid and Medicare services Medicaid and Medicare services

In the next section, you will learn more about the three types of Plans and the services they provide.

Step 1

Pick the type of Plan you want

How to Choose a Plan

Selecting a Managed Long Term Care Plan is important. Discuss your Plan options with your family, doctor, or the person who helps you make your health care decisions.

You can take the three steps in this Guide to help you select a Managed Long Term Care Plan.

Your first step is to pick the type of Plan you want. In the next few pages, three Plan Members describe their type of Plan and they also tell you why they chose it. You can then decide which Plan you prefer.

■ MLTC Medicaid Plan

"I didn´t want to change doctors or anything with my Medicare services. That´s why I chose a MLTC Medicaid Plan. My Plan focuses solely on home care and my other long–term care services. It´s separate from Medicare. So, when I see my primary care doctor or need any Medicare services, I still use my Medicare card."

Plan Services

Here are some of the services provided by a MLTC Medicaid Plan

Medicaid long term care services

  • Health Services at your home
    • Nurses
      Home Health Aides
      Physical Therapists
  • Personal Care
    • Help with bathing,
      dressing,
      and grocery shopping
  • Adult Day Health Care
  • Social Day Care
  • Nursing Home Care
  • Specialty Health
    • Audiology
      Dental
      Optometry
      Podiatry
      Physical Therapy
  • Other Services
    • Home–delivered meals
      Personal emergency response
      Transportation to medical appointments

As a Plan member, you are free to keep seeing your Medicare or Medicare Advantage doctor or other provider of services not covered by the Plan.

♦ Medicaid Advantage Plus Plan

"I like getting all my care from one Plan. It´s why I chose Medicaid Advantage Plus. My Plan manages both my Medicaid and Medicare services. Now my doctors, hospital, and home care agency are all in the same Plan."

You must also join the Plan´s Medicare Product. You choose a Primary Care Physician (PCP) from the Plan to be your regular doctor.

Plan Services

Here are some of the services provided by a Medicaid Advantage Plus Plan

Medicaid long term care services

  • Health Services at your home
    • Nurses
      Home Health Aides
      Physical Therapists
  • Personal Care
    • Help with bathing,
      dressing,
      and grocery shopping
  • Adult Day Health Care
  • Social Day Care
  • Nursing Home Care
  • Specialty Health
    • Audiology
      Dental
      Optometry
      Podiatry
      Physical Therapy
  • Other Services
    • Home–delivered meals
      Personal emergency response
      Transportation to medical appointments

Medicare Services

  • Doctor office visits
  • Specialty care
  • Clinic visits, hospital stays
  • Mental health services
  • X–ray and other Radiology services
  • Chiropractic care
  • Medicare Part D drug benefits
  • Ambulance services

⚫ Program for All–Inclusive Care for the Elderly PACE

"I don´t like to be alone at home so I chose PACE because of the Plan´s adult day center. I can spend the day there with other Plan members. My doctor and Care Team are also at the day center, so I get my health services there as well. "

You have to be at least 55 years old to join PACE.

PACE health services are provided by a Team that includes doctors, nurses, social workers and others.

Plan Services

Here are some of the services you get from PACE

Medicaid long term care services

  • Health Services at your home
    • Nurses
      Home Health Aides
      Physical Therapists
  • Personal Care
    • Help with bathing,
      dressing,
      and grocery shopping
  • Adult Day Health Care
  • Social Day Care
  • Nursing Home Care
  • Specialty Health
    • Audiology
      Dental
      Optometry
      Podiatry
      Physical Therapy
  • Other Services
    • Home–delivered meals
      Personal emergency response
      Transportation to medical appointments

Medicare Services

  • Doctor office visits
  • Specialty care
  • Clinic visits, hospital stays
  • Mental health services
  • X–ray and other Radiology services
  • Chiropractic care
  • Medicare Part D drug benefits
  • Ambulance services

Step 2

Fill out the Provider Worksheet

Provider Worksheet

Now that you know the type of Plan you want; New York Medicaid Choice can help you select a Plan with the providers you have now.

Write their names here.

Personal Care or Home Attendant Agency Certified Home Health Agency

____________________________________________________________________

Other Agency or Professional who visits you at home

____________________________________________________________________

Adult Day Health Care Program

____________________________________________________________________

Dentist

____________________________________________________________________

Optometrist (eye doctor)

____________________________________________________________________

Podiatrist (foot doctor)

____________________________________________________________________

If you are interested in Medicaid Advantage Plus or PACE:

Your PCP (Primary Care Physician)

____________________________________________________________________

Your Specialty Physician

____________________________________________________________________

Step 3

Enroll in Your Plan

Call New York Medicaid Choice

1–888–401–6582
TTY: 1–888–329–1541

Our counselors will answer your questions and also:
  • Confirm the type of Plan you want to join
  • Look up which Plans work with the home care agency and other providers you are seeing now, or want to see as a Plan member
  • Enroll you in a MLTC Medicaid Plan over the phone or TTY
  • If you want to join a Medicaid Advantage Plus Plan or PACE, our counselors will explain the process and transfer you to the Plan you want to join.

After You Join a Plan

After you enroll in a Plan, you will get a confirmation letter from New York Medicaid Choice that tells you the date when you start with your new Plan.

You will also get a Member Handbook and a Plan Identification Card from your new Plan. Your Member Handbook includes the services your Plan provides and other important information.

Your Care Manager will also work with you and anyone else you want to involve, to assess your service needs and develop a Plan of Care. Your Plan of Care will describe the services you will get from your Plan.

Transitional care

During the first 60 days in a Plan, your Care Manager will arrange for you to keep the same services you had before you joined the Plan.

If you have Special Needs

Your Care Manager will assist you if you need support to meet a specific need. Plans provide:

  • Information in large print or other formats
  • TTY services for people who have trouble hearing or speaking
  • Translation services
  • Plan providers with wheelchair access or other accommodations.

Your Rights as a Plan Member

As a Plan member, you have certain rights, such as the right to:

  • Get timely access to services that help with or prevent a health problem or disability
  • Be told where, when and how to get needed services from your Plan or outside the Plan
  • Be told what you need to know to give informed consent about your care
  • Take part in decisions about your health care including the right to refuse treatment
  • Get care without regard to sex, race, health status, color, age, national origin, sexual orientation, marital status, or religion
  • Privacy about your medical record and when you get treatment
  • Get a copy of your medical records and to ask that the records be amended or corrected
  • Be treated with respect and dignity
  • Be free from any form of restraint or seclusion used as a means of force, discipline, convenience or retaliation.
Your Responsibilities as a Plan Member

As a Plan member, you also have responsibilities.

You should always:

  • Use providers who work with the Plan for covered services
  • Get approval from your Care Manager or care team before receiving a covered service
  • Tell the Plan about your care needs and concerns
  • Tell the Plan when you go away or out of town
  • Some people with a certain income must pay a surplus amount (also called spend down) to get Medicaid benefits. As a Plan member, you are responsible for paying this amount to the Plan.

Changing Plans

You may ask to change Plans at any time. If you want to change Plans, contact the Plan you want to join. If you are not sure which Plan you want to select – call New York Medicaid Choice. Our counselors will be glad to assist you.

Your Plan must continue to arrange and pay for your services until your new Plan takes over. Disenrollment takes place at the end of the month.

Unless you are not required to join a Plan, you must remain in a Plan to receive long term care services in your community. You cannot receive these services outside a Plan.

Problem Solving

Feel free to speak to your Care Manager about any concerns you may have with your Plan of Care or services. If you are still not satisfied with the results of your complaint, you may also do the following:

  • Contact New York Medicaid Choice. Our counselors will contact the Plan and try to help you resolve the problem.

What is a Grievance?

A grievance is a way of making a complaint. If you are not happy with something about your services or with someone from the Plan, you can complain. You or someone on your behalf can file a grievance in writing, over the phone or in person. Your Plan will work with you to resolve the problem.

What is an Appeal?

If your Plan denies, reduces, or ends services that you think you should have – you can appeal. The Plan will take another look at your service needs and will send you a letter with their decision. If you still are not satisfied, you can ask for a Fair Hearing.

When you ask for a Fair Hearing – the Medicaid Program will listen to your case and make a decision.

Who Does Not Have to Join a Plan

The following people are not required to join a Managed Long Term Care Plan. They may join a Plan if they want:

  • Native Americans
  • Adults age 18 – 20 who need more than 120 days of community–based long term care
  • Adults who are nursing home eligible and enrolled in the Medicaid Program for the working disabled.

People receiving the following services cannot join a Managed Long Term Care Plan. In some cases, you may leave your program to join a Plan.

  • People enrolled in an Assisted Living Program
  • People enrolled in the Traumatic Brain Injury (TBI), Nursing Home Transition & Diversion, or Long Term Home Health Care Program waivers
  • People participating in the Consumer Directed Personal Assistance Program (CDPAP)
  • People receiving hospice services or who are residents of a psychiatric or residential care facility or nursing home
  • People who have a developmental disability and receiving care in a facility, in the community or through a waiver program, and those who have similar needs
  • People who live in Family Care Homes licensed by the Office of Mental Health
  • Residents of alcohol and drug abuse residential treatment programs
  • People who have Medicaid eligibility only for tuberculosis–related services
  • People who are uninsured and receiving breast and cervical cancer services and those who are under age 65 and eligible for the early detection program
  • People who have Medicaid eligibility only for breast and cervical cancer services
  • People who are eligible for family planning expansion program
  • People with less than 6 months of Medicaid eligibility or eligible for emergency Medicaid only.

Contact New York Medicaid Choice
if you are receiving any of the above services and you have questions. Counselors will be glad to assist you.
Call: 1–888–401–6582
TTY: 1–888–329–1541

New York Medicaid Choice
1–888–401–6582
TTY: 1–888–329–1541

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