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Major Changes Looming in Medicaid Home Care

by Lori R. Somekh on Aug. 16, 2017

 General Practice 

Summary: Effective July 1, 2012, New York State has begun implementing the privatization of the Medicaid Home Care Program. The new program is mandatory and is being phased in over the next two years. It is slated to be fully phased in by June, 2014.

Effective July 1, 2012, New York State has begun implementing the privatization of the Medicaid Home Care Program.  The new program is mandatory and is being phased in over the next two years.  It is slated to be fully phased in by June, 2014.  Anyone who has both Medicare and Medicaid will be required to enroll in a Managed Long-Term Care (MLTC) plan in order to receive Medicaid home care benefits.

What is Managed Long-Term Care?

MLTC is a system of Managed Care Organizations (MCOs) which provide care management and integrated care delivery through a network of providers that contract with the plan.  The MCOs will be paid by Medicaid through a system known as “capitation.”

 What is “capitation”?

Capitation refers to a system whereby Medicaid pays a set monthly fee, per enrollee, to a local non-government contractor to provide the broad range of services required to deliver long-term care to Medicaid beneficiaries. The contractor (i.e., the MCO), coordinates care across the range of services the client receives. The contractor also assumes either full or partial financial risk, depending on the program.

Capitation allows states to pay one fixed fee for each enrollee. This limits the state’s financial risk, shifting it to the MCO, and makes it easier for the state to predict its long-term care costs over time.

 There are two different types of MLTC plans in New York:

     1.  Partially Capitated.  The plan is limited to Medicaid long-term care services and certain other limited services.  It does not include all primary care.  It does not included Medicare services.  This means a client can continue seeing his or her primary care providers and providers for other services not included in the plan. 

Covered MLTC services will likely be services such as the personal care attendants, home health aides, adult day care, dental care and transportation.  Most clients who presently have home care through the local Department of Social Services or the Medicaid field offices (CASAs in NYC) will be using these plans.  The transition into the plans will be addressed below. 

       2.   Fully Capitated.  This plan is all inclusive.  It encompasses all Medicaid and Medicare services.  This includes primary care, acute, hospital, behavioral and long term care services.  In this case the member may have to change all of his providers.

Programs included in this type of plan are:

1.      Program of All-Inclusive Care for the Elderly (PACE). PACE provides both primary medical care AND long-term care services, including all services paid for by Medicare and Medicaid.  Members are required to use PACE network physicians, home care providers, hospitals, and other providers.

2.      Medicaid Advantage Plans.  These plans provide and control access to all primary medical care paid for by MEDICARE and MEDICAID, but they do not cover most of the long-term care services provided by Medicaid or Medicare.

3.      Medicaid Advantage Plus (MAP).  Like PACE, the MAP plan also provides both primary medical care AND long-term care services provided by Medicare and Medicaid, members are required to use the in-network providers, as well.

When is the new system being implemented?

The new system is being phased in according to the following schedule:

--During the period from July through August, New York City Medicaid Home Care recipients were converted to an MLTC.

--Between September and October, Bronx recipients received notices and were converted to an MLTC.  

--At the end of December, notices went out to Queens and Staten Island recipients. 

 --Nassau, Suffolk and Westchester County recipients should be getting notices in January, 2013.

 --Rockland and Orange County recipients should receive notices in June, 2013. 

 --Albany, Erie, Onondaga and Monroe Counties should receive notices in December, 2014. 

 --All other counties should receive notices by June, 2014.

  How will the transition occur?

The first thing recipients will receive is a “60-Day Notice” or “First Notice,” containing an enrollment packet.  This will be a notice advising that the individual must enroll in an MLTC plan within 60 days or he/she will be automatically assigned randomly to a plan.  This notice will include a list of plans and some explanatory material.

Recipients will then receive a “Second Notice” thirty days after the First Notice.  Then, forty-five days after the First Notice, they will receive a “Third Notice.”  This notice will contain the name of the plan to which the recipient will be automatically enrolled.

 Sixty days after the First Notice, a Fourth Notice will be sent, informing the recipient of the MLTC to which he or she was automatically assigned.  The assignment will be effective as of the first day of the following month.

Is the care the same under the new plan?

New York State did not change the medical eligibility criteria for home care.  Nor has there been any change in the amount or type of services available.  Initially, the MLTCs are required to ensure that individuals have continuity of the long term care services they are currently receiving.  In New York City, all MLTC plans must contract with all home attendant vendors that presently have contracts with the current Human Resources Administration (HRA). 

The MLTC must continue the same hours and the same services with the same provider for 60 days or until it does a reassessment, whichever is later. 

Does this sound confusing?

It is!  Although the eligibility criteria and the available services have not changed, the entire process of applying for the Medicaid and arranging for the care is now different.  All of the practitioners in New York are in the process of learning the new system and helping our clients make the transition.  New home care clients will go right into the new system.  Existing clients will be converted into it according to the above schedule.  As always, Somekh & Associates will walk you through the process.

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