MLTC Policy 13.05

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.05: Social Daycare Services Questions and Answers

Date of Issuance: February 28, 2013


This document answers questions that the Department has received since the release of MLTC Policy #13.03 regarding social daycare services:

1. Can a Medicaid recipient who is attending a Social Daycare Program be eligible for enrollment in a managed long term care (MLTC) plan?

A. A requirement for eligibility in a MLTC plan is for the consumer to be in need of more than 120 days of Medicaid community based long term care (CBLTC). Medicaid CBLTC is defined as: personal care services, home health care services, private duty nursing services or adult day health care. If a consumer meets the criteria of needing more than 120 days of CBLTC, they may be enrolled into a MLTC plan. The Department recognizes that a consumer may have ongoing need for Medicaid CBLTC that may be met by alternate means (e.g. family or friends), but this need must be determined and documented in the MLTC assessment and identified in the Plan of Care. Any ongoing need for Medicaid CBLTC must continue to be determined and documented in the assessment and identified in the Plan of Care. If no need exists the MLTC plan must initiate a disenrollment pursuant to the plan's contract provisions.

2. Can Social Daycare be used as a substitute for personal care services?

A. Simply attending Social Daycare for 120 days or longer does not meet the eligibility standard for MLTC. MLTC plans cannot enroll a Medicaid recipient in a social daycare program unless they have a functional or clinical need for Medicaid CBLTC services and such need must be determined and documented by the MLTC assessment and identified in the Plan of Care. Additionally, MLTC plan of care must document what services are provided in the Social Daycare program that meets the assessed needs of the enrollee. Social Daycare should not represent an individual's complete plan of care. At any time, the review of eligibility for enrollment, a plan of care, and the services delivered, may be audited by the Department or the Office of the Medicaid Inspector General.

3. What is the effective date of the policy affecting the use of Social Daycare as a condition of eligibility for MLTC?

A. The policy will be effective January 25, 2013 coinciding with the release of MLTC policy #13.03.