MLTC Policy 13.11

Letter from State Medicaid Director Helgerson to MLTC Plans on SADC

Dear Managed Long Term Care Plan:

With recent press reports alluding to inappropriate utilization of social day care and enrollment of non-medically eligible recipients into Managed Long Term Care (MLTC) Plans, it is imperative you review and comply with all operative policies and requirements.

Plans must consider the individual needs of each enrollee during the assessment process and must clearly identify the need for social day care as a service in the plan of care. MLTC plans should not enroll a recipient in social day care unless the recipient has a functional or clinical need for community based long term care services (CBLTCS) - defined specifically as personal care services in the home, home health care, private duty nursing, consumer directed personal assistance services, and adult day health care. The need for the CBLTCS must be documented during the initial assessment process, clearly identified in the plan of care, and evaluated on an ongoing basis during reassessments. Social day care can contribute to the total care plan but cannot represent the primary service provided to the enrollee as detailed in MLTC Policy 13.03: Community Based Long Term Care Services. Enrollees who no longer demonstrate a functional or clinical need for CBLTCS need must be disenrolled from their MLTC plan.

Effective immediately, the Department of Health is mandating that all MLTC plans reassess any member currently receiving social day care as a plan benefit. Current Semi-Annual Assessment of Members (SAAMs) and the corresponding plan of care must be reviewed to determine if social day care is considered an appropriate benefit. The need for social day care should be clearly identified in the plan of care and benefits from participation in a social day care program should be documented.

MLTCs should also be aware that the Office of the Medicaid Inspector General (OMIG) will conduct audit activities on all enrollments per the OMIG workplan and the Department will recoup any capitation payments made for non-eligible enrollees.

In addition, the Department is receiving reports of marketing violations. MLTC plans and providers of plan services may not offer materials, financial gain or service incentives to recipients as an inducement to enroll in a MLTC plan or to transfer MLTC plans. No MLTC marketing activities should be conducted at any social day care site and plans should not accept referrals from a social day care site. MLTCs must adhere to the Department-approved marketing guidelines, detailed in MLTC Policy 13.06: Marketing Guidelines for Managed Long Term Care Plans and Medical Service Providers. Potential enrollees seeking information on MLTCs should be directed to contact the Department´s enrollment broker, NY Medicaid Choice, at 1-888-401-6582.

Thank you for your immediate attention to these matters.

Sincerely,

Jason A. Helgerson
New York State Medicaid Director
Office of Health Insurance Programs