MLTC Policy 13.21:

Process Issues Involving the Definition of Community Based Long Term Care

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

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.21: Process Issues Involving the Definition of Community Based Long Term Care Services

Date of Issuance: August 12, 2013

The purpose of this policy is to further clarify MLTC Policies 13.15 and 13.16 as they relate to the definition of community based long term care. As referenced in those previous policies, individuals who only require assistance with housekeeping tasks do not meet the intent of community based long term care services.

Any individuals not presently in receipt of Personal Care Services or Consumer Directed Personal Assistance Services who are initially assessed by the MLTC plan as needing only Level I services, do not meet the threshold for enrolling into MLTC. Therefore, local districts of social services (LDSS) have been directed to resume accepting and processing new applications involving solely Level I services. Individuals should be referred to the LDSS for assessment and if determined to be in need of Level I services only, the local district will establish the case on a fee for service basis and provide appropriate notice to the Medicaid recipient. If an individual disagrees with the plan´s determination that they are inappropriate for enrollment, and the individual wishes to pursue enrollment to a MLTCP, the plan must follow denial of enrollment protocols including Fair Hearing rights.

Individuals with a need for assistance with both Instrumental Activities of Daily Living (e.g. housekeeping tasks) and Activities of Daily Living (e.g. bathing, grooming, toileting etc) and meeting the eligibility standard of requiring more than 120 days of community based long term care services will continue to be appropriate for MLTC enrollment. Upon periodic reassessment of MLTC members, whether at six months, 90 days, or at change of condition, if it is determined that the member solely requires discrete housekeeping services, they should be considered no longer MLTC eligible and be disenrolled.

Medicaid eligible individuals already enrolled in MLTC whose assessment determines Level I to be the sole community based long term care service required, must be disenrolled and referred by the plan to the local district if the individual agrees they are not appropriate for the MLTC continued enrollment. If the individual disagrees, involuntary disenrollment is followed with appropriate Fair Hearing rights, including the option for aid to continue. Within five (5) business days from the date it was determined the individual is not eligible for MLTC the plan must provide the individual with appropriate notice. Such notice, together with the results of its assessment, must be provided by the plan to the local district or entity designated by the Department. In addition to standard language contained in a disenrollment notice, that notice must explain that though disenrolled, the individual´s Level 1 services will continue unchanged but will now be authorized and managed by the local district. The effective date of disenrollment shall be the first day of the month following the month in which the disenrollment is processed through eMedNY. Plans must transmit to the local district, or entity designated by the Department, a copy of the notice, together with the results of its assessment, the service plan, and the name and contact information for the housekeeping vendor or fiscal intermediary. In situations where such an individual had 90 days of Medicaid eligibility at the time of transition, the plan must assist in submitting the individual´s Medicaid application to the local district to assure continuing Medicaid coverage. Plans should make every effort to transition cases to the local district, or entity designated by the Department, as soon as possible but no later than noon on the 20th of the month.

Individuals transitioning from MLTC to fee for service Level I services will continue to receive services under the individual´s pre-existing service plan for at least 90 days after transitioning to fee for service or until a care assessment has been completed by the LDSS, whichever is later. In addition, the patient/worker(s) relationship will attempt to be preserved for the same 90 day period.