Important Changes to NYS MLTC Program

The Centers for Medicare and Medicaid Services (CMS) have approved a carve out, or exception, in New York State to enrollment in the Managed Long Term Care (MLTC) program for individuals who have been a permanent resident of a nursing home for more than three months. CMS issued a letter approving NYS’s request for the policy change on December 19, 2019.

This policy reverses a prior policy enacted in 2015 that expanded the MLTC program to nursing home residents.  Under the old policy, Medicaid home care recipients who went into a nursing home remained enrolled in their existing MLTC plan. In addition, individuals entering a nursing home who had not been enrolled in an MLTC were required to enroll in one upon being approved for nursing home Medicaid.  The MLTC plan was then responsible for paying the cost of nursing home care for those enrollees.

Under the new policy, recipients of nursing home Medicaid who have resided in a nursing home for 90 days or more and are enrolled in an MLTC plan will be involuntarily disenrolled from the MLTC plan.  Nursing home Medicaid recipients who were not enrolled in an MLTC plan will no longer be required to enroll in one.

The New York State Department of Health (DOH) will roll out this change in three stages starting January 2020.

  1. Nursing home residents for over 90 days who are 21 and older, have Medicare and are not enrolled in an MLTC are no longer required to enroll in one, and enrollments scheduled for February 1, 2020 have been canceled.
  2. MLTC members have been notified of this change for residents of nursing homes over 90 days via an informational notice sent out by the DOH.
  3. NY Medicaid Choice will send notices regarding the disenrollment to MLTC enrollees who are 21 and over, have Medicare and have been residents of nursing homes for longer than 90 days. MLTC members outside of NYC will be mailed notification by March 1, 2020 and those inside NYC by April 1, 2020. Upon disenrollment, the nursing home will be paid by Medicaid on a fee-for-service base.

Advocates are concerned that relieving MLTCs of the responsibility of paying for nursing home care will result in the approval of insufficient levels of home care for Medicaid applicants who have a need for 24-hour or other high-hour care. Since MLTCS are no longer responsible for the cost of nursing home care after 90 days of residency in a nursing home, they are no longer incentivized to authorize high levels of home care that would otherwise cost them less than nursing home care.  The concern is that MLTCs will decrease their approval of higher-hour levels of home care.  For those individuals who need such higher levels of home care because of the severity of their disabilities, this change may result in an inability to be able to safely reside at home and a need to go into a nursing home unnecessarily.  A summary of advocates’ concerns about the policy change can be found here.

In addition, this change makes the enrollment in home care services much more difficult for individuals who enter a nursing home on a temporary basis with the expectation of ultimately going home with the appropriate level of home care.

A related change is that CMS approved an MLTC “lock in,” barring members who enroll in a new plan from changing plans for nine months after the first 90-day enrollment period.

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