MLTC Overview:

Managed Long Term Care (MLTC) is a system that streamlines the delivery of long term services to people who are chronically ill or disabled and who wish to stay in their homes and communities.

These services, such as home care or adult day care, are provided through MLTC Plans that are approved by the New York State Department of Health (NYSDOH).

The entire array of services to which an enrolled member is entitled can be received through the MLTC plan the member has chosen

Transition Status:

Mandatory MLTC began in September 2012 and the transition was complete in July 2015.

Eligibility for MLTC:

Dual eligible individuals (having both Medicare and Medicaid), who are age 21 and older and who are assessed as needing community based long term care services for more than 120 days must enroll in MLTC in order to receive those services.

Effective 7/1/15 on a statewide basis, dual eligible Nursing Home residents who are age 21 and older and determined to need permanent Nursing Home placement must join a MLTC Plan.

The following may voluntarily enroll in MLTC:

1. dual eligible individuals, age 18–20, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for more than 120 days; and
2. non–dual eligible individuals, age 18 and older, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for more than 120 days.

Eligibility Requirements:

An individual must be:

• determined eligible for Medicaid by the Local Departments of Social Services or entity designated by the Department;
• determined eligible for MLTC by the MLTC Plan using the Uniform Assessment System (UAS–NY) eligibility assessment tool;
• capable, at the time of enrollment, of returning to or remaining in his/her home and community without jeopardy to his/her health and safety, based upon criteria provided by the Department; and
• expected to require at least one (1) of the following services covered by the MLTC Plan for more than 120 days from the effective date of enrollment:
  • nursing services in the home;
  • therapies in the home;
  • home health aide services;
  • personal care services in the home;
  • adult day health care;
  • private duty nursing; or
  • Consumer Directed Personal Assistance Services.
• The potential that an Applicant may require acute hospital inpatient services or nursing home placement during such 120 day period shall not be taken into consideration by the Contractor when assessing an Applicant´s eligibility for enrollment.

Populations Excluded and Exempt from Enrollment (Table 1):

Population	MLTC Excluded	MLTC Exempt	Notes (Information in this chart is current as of 4/2023)
Residents of psychiatric facilities	X
Individuals expected to be Medicaid eligible for less than six (6) months	X
Individuals eligible for Medicaid benefits only with respect to tuberculosis–relate services	X
Individuals with a "county of fiscal responsibility" code of 78 (New York State of Health) or 99 (i.e., eligible only for breast and cervical cancer services) in eMedNY or a successor system	X
Individuals receiving hospice services at the time of enrollment	X
Individuals with a "county of fiscal responsibility" code of 97 (i.e., residing in a state Office of Mental Health (OMH) facility) in eMedNY or a successor system	X
Individuals with a "county of fiscal responsibility" code of 98 (i.e., individuals in an Office for People with Developmental Disabilities (OPWDD) facility or treatment center) in eMedNY or a successor system	X		MAP -excluded until program features are approved by the State and operational at the local district level to permit these individuals to voluntarily enroll in MAP
Individuals eligible for the family planning expansion program	X
Individuals under sixty–five (65) years of age in the Centers for Disease Control and Prevention breast and/or cervical cancer early detection program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage	X
Residents of intermediate care facilities for the developmentally disabled (ICF/DD)	X
Individuals who could otherwise reside in an ICF/DD, but choose not to do so	X
Residents of alcohol/substance use disorder long term residential treatment programs	X
Individuals eligible for Emergency Medicaid	X
Individuals in the OPWDD Home and Community Based Services section 1915(c) waiver program	X
Individuals in the following section 1915(c) waiver programs: Traumatic Brain Injury, and Nursing Home Transition & Diversion	X
Residents of Assisted Living Programs (ALP)	X
Individuals in receipt of Limited Licensed Home Care Services	X
Individuals in the Foster Care	X
Residents of skilled nursing or residential health care facilities with an active LTNHS designation are excluded from enrollment in a MLTC Partial Capitation plan	X
Individuals with private Long Term Care insurance	X
Individuals aged 18-21 who are nursing home certifiable and require a continuous period of more than 120 days of community based long term care services		X
Native Americans/Alaskan Natives		X
Individuals who are eligible for the Medicaid buy-in for the working disabled and are nursing home certifiable		X
Aliessa Court Ordered Individuals		X

Sources: 2017-2021 MLTC Model Contracts, 1115 Waiver, and NYS Partnership for Long Term Care

Covered Services:

• The covered services provided by MLTC Plans must comply with all standards of the New York State Medicaid Plan established pursuant to Social Services Law (SSL) § 363–a and satisfy all other applicable requirements of SSL and Public Health Law.
• See Appendix G Managed Long Term Care Covered/Non–covered Services contained within the informational packet.

New to service:

• For individuals requesting community based services who are not currently receiving services, must go to the Conflict Free Evaluation and Enrollment Center (CFEEC).
• In accordance with NY State´s Special Terms and Conditions #28 , the state was required to develop an independent and conflict–free long term care services and supports (LTSS) evaluation process.
• Effective October 2014, the state implemented the CFEEC for individuals seeking Community Based Long Term Care (CSLTC) services for more than 120 days.
• CFEEC will be the only entity authorized to complete initial evaluations.
• Managed Long Term Care Plans will no longer be permitted to enroll new individuals until the CFEEC has conducted an initial evaluation to determine CSLTC eligibility.
• MLTC Plans will continue to be responsible for completing their own assessments which determine the plan of care.
• This policy does not apply to individuals transferring from one plan to another.
• The CFEEC will evaluate consumer´s eligibility for one of the four MLTC products:
  • Partially Capitated Plans
  • Program of All–Inclusive Care for the Elderly (PACE)
  • Medicaid Advantage Plus (MAP)
  • Fully Integrated Duals Advantage (FIDA) (demonstration counties only)

Services, When Provided, Would Be Covered by the Capitation1, 2	Non–Covered Services; Excluded From The Capitation; Can Be Billed Fee–For–Service
Services Provided as Medically Necessary:
Care Management	Inpatient Hospital Services
Nursing Home Care	Outpatient Hospital Services
Home Care Nursing Home Health Aide Physical Therapy (PT) Occupation al Therapy (OT) Speech Pathology (SP) Medical Social Services	Physician Services including services provided in an office setting, a clinic, a facility, or in the home.3
Adult Day Health Care	Laboratory Services
Personal Care	Radiology and Radioisotope Services
DME, including Medical/Surgical Supplies*, Enteral and Parenteral Formula#, and Hearing Aid Batteries, Prosthetics, Orthotics and Orthopedic Footwear**	Emergency Transportation
Personal Emergency Response System	Rural Health Clinic Services
Non–emergent Transportation	Chronic Renal Dialysis
Podiatry	Mental Health Services
Dentistry	Alcohol and Substance Abuse Services
Optometry / Eyeglasses	OPWDD Services
PT, OT, SP or other therapies provided in a setting other than a home. Limited to 20 visits of each therapy type per calendar year, except for children under 21 and the developmentally disabled. MLTC plan may authorize additional visits.	Family Planning Services
Audiology / Hearing Aids	Prescription and Non–Prescription Drugs, Compounded Prescriptions
Respiratory Therapy	Assisted Living Program
Nutrition	All other services listed in the Title XIX State Plan
Private Duty Nursing
Consumer Directed Personal Assistance Services
Services Provided Through Care Management:
Home Delivered or Congregate Meals
Social Day Care
Social and Environmental Supports

<sup>1. The capitation payment includes applicable Medicare coinsurance and deductibles for benefit package services.  1
2. Any of the services listed in this column, when provided in a diagnostic and treatment center, would be included in and covered by the capitation payment.  2
3. Includes nurse practitioners and physician assistants acting as "physician extenders".  3</sup>
* Compression and support stockings are limited to coverage only for pregnancy or treatment of venous stasis ulcers
# Enteral formula limited to nasogastric, jejunostomy, or gastrostomy tube feeding; or treatment of an inborn error of metabolism.
** Prescription footwear and inserts are limited to use in conjunction with a lower limb orthotic brace, as part of a diabetic treatment plan, or if there are foot complication in children under age 21.