MLTC Policy 13.01 REVISED

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.01 REVISED: Transition of Care for Fee for Services Participants in Mandatory Counties

Date of Issuance: February 6, 2013

The purpose of this policy is to clarify that members transitioning from FFS Medicaid are afforded protections related to continuity of care.

The Partnership Plan terms and conditions (28 (d)) require:

  • Each enrollee who is receiving community-based long-term services and supports, as specified below, that qualifies for MLTC must continue to receive services under the enrollee´s pre-existing service plan for at least 60 days after enrollment, or until a care assessment has been completed by the MCO/PIHP, whichever is later.
  • Any reduction, suspension, denial or termination of previously authorized services shall trigger the required notice under 42 C.F.R . § 438.404, mailed at least ten days before the proposed effective date of the change (as required by 42 C.F.R. § 431.211), that clearly articulates the enrollee´s right to file an internal appeal (either expedited, if warranted, or standard), the right to have authorized services continue pending the resolution of the internal appeal, and the right to a fair hearing if the plan renders an adverse determination (either in whole or in part) on the internal appeal.

Therefore plans must treat all enrollees (age 21 and over eligible for Medicaid and Medicare) in mandatory counties transitioning from fee for service Medicaid in the same manner related to continuity of care and access to aid to continue through the internal appeal and fair hearing processes.

This means that, for any individual receiving fee for service Medicaid community based long term services and supports, as specified below, and enrolling under any circumstance, the plan must provide 60 days of continuity of care. Further, if there is an internal appeal or fair hearing as a result of any proposed Plan reduction, suspension, denial or termination of previously authorized services, the Plan must comply with the aid to continue requirement identified above. In particular, if the enrollee requests a State fair hearing to review a Plan adverse determination that is upheld after an internal appeal, aid-to- continue is to be provided until the fair hearing decision is issued.

This policy applies to the following Medicaid fee-for-service community based long term care services and supports:

  • Personal care services;
  • Consumer directed personal assistance;
  • Home health services;
  • Private duty nursing; and
  • Adult day health care