MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC

Office of Health Insurance Programs
Division of Long Term Care
MLTC Policy 15.02: Transition of Medicaid Managed Care Enrollees to Managed Long Term Care
Date of Issuance: June 15, 2015

On April 1, 2015, the Division of Health Plan Contracting and Oversight issued a policy designed to provide for an orderly disenrollment of Medicaid Managed Care (MMC) enrollees who become eligible for Medicare coverage.

To ensure that MMC enrollees receiving Community Based Long Term Care (CBLTC) do not experience a lapse in coverage, they will be enrolled in a Managed Long Term Care Plan (MLTCP), unless otherwise exempt or excluded. CBLTC services are defined as Nursing, Home Health Care, Personal Care, Consumer Directed Personal Assistance Services (CDPAS), and Adult Day Health Care. Level 1 Housekeeping does not qualify as CBLTC.

MMC enrollees in receipt of or expected to need CBLTC services for more than 120 days, as verified by the Mainstream Managed Care Plan (MMCP), do not have to be assessed by the Conflict Free Evaluation and Enrollment Center (CFEEC) in order to be enrolled in an MLTCP. Once identified as eligible for Medicare coverage, affected Medicaid enrollees will be referred to the State´s Enrollment Broker, New York Medicaid Choice (NYMC), which will provide educational materials on MLTCP options. Enrollees who do not select an MLTCP will be transferred into an MLTC Partial Capitation Plan by New York State (the State). MMCP enrollees whose plan has an affiliated MLTC Partial Capitation Plan will be transferred seamlessly into that MLTCP by the State. If the MMCP does not have an affiliate MLTC product, the State will select an appropriate MLTCP for enrollment. MLTC enrollees will continue to have the option to transfer to another MLTCP at any time.

NYMC will educate these MMC enrollees on all MLTC product options, including Program of All Inclusive Care for the Elderly (PACE), Medicare Advantage Plus (MAP), and Fully Integrated Duals Advantage (FIDA). Enrollees who do not make a selection will only be transferred to an MLTC Partial Capitation Plan. MMCPs will work with the receiving MLTC Plan to provide information on the enrollee´s plan of care. The MLTC Plan must honor continuity of care for 90 days.

In districts that are not yet mandatory for MLTC enrollment, or may not yet have an approved MLTC plan available, the MMCP must initiate referral to the LDSS for personal care services/CDPAS if the enrollee is receiving those services or to a Certified Home Health Agency, as appropriate.

Enrollees not in receipt of LTSS will be referred to NYMC which will provide education on the option of enrolling in a Medicaid Advantage plan, if available in their district. If a Medicaid

Advantage plan is not selected, the individual will be disenrolled to fee-for-service Medicaid. New York Medicaid Choice (NYMC) will be available to enrollees for Medicaid Advantage plan selection and transfer in New York City, Nassau, Suffolk, and Westchester Counties. Transfer to Medicaid Advantage in other areas will be completed by the Local Department of Social Services. Appeal rights and procedures will be identified in all related enrollee notices.

Please note that this transfer process will also impact those MMC enrollees whose Medicaid rebudgeting identifies spenddown. Those enrollees in need of CBLTC will need to be transferred to MLTC Plans, or referred to LDSS in districts not yet mandatory for MLTC.

MMC Transition Process

NYMC will send MMCP enrollees a letter two to four months prior to their 65th birthday. The letter will instruct the individual to contact NYMC if he/she becomes eligible for Medicare. MMCPs will provide information to NYMC identifying their enrollees in receipt (and continued need) of CBLTC. NYMC will send a notice to enrollees identified as receiving CBLTC, instructing them to contact NYMC for education on enrollment options. Enrollees in an MMCP having an affiliated MLTC Partial Capitation product will be seamlessly transferred to their plan´s MLTC Partial Capitation Plan unless the enrollee selects a different option.

For enrollees identified as being in receipt of LTSS and whose plan does not have an affiliated MLTCP, NYMC will conduct outreach to explain the need to choose an MLTCP to prevent any lapse in coverage. NYMC will send a notice 45 days prior to disenrollment and this notice will direct enrollees to contact NYMC to select an MLTCP for enrollment in order to avoid a gap in coverage. If the enrollee does not select a plan within 30 days, he/she will be auto-assigned into an MLTC Partial Capitation Plan to assure continuance of LTSS.