Clarification on how to process and what are the required steps to take for a Medicaid individuals who requires only Personal Care Level 1 services in a MLTC plan. This clarifies previous MLTC policies 13.15 and 13.16. 

DOH has issued a policy update regarding an on-going review of Pharmacy claims which determined that certain Durable Medical Equipment (DME) items were being inappropriately billed as a Pharmacy claim. These billing errors resulted in a fee-for-service payment of items that are included in the capitation payment to Managed Long Term Care Plans (MLTCP).

DOH provided updates during the July 19 DOH Managed Long Term Care (MLTC) Implementation Advisory Group call.

The purpose of this policy document is to remind Managed Long Term Care (MLTC) plans of the need to effectively coordinate Medicare and other third-party liability benefits for the MLTC dual-eligible membership.  Federal regulations require Medicaid to be the payer of last resort.

This GIS further clarifies MLTC policies as it pertains to Level 1 personal care services as the sole community-based long term care service provided to a consumer.

As per Special Terms and Conditions (STC) #28 (d), MLTC plans must submit data for state review on a monthly basis when the plan has issued a notice of action that involves a reduction of split-shift or live-in services or when the plan is reducing hours by 25 percent or more.

LeadingAge NY continues to advocate for answers and clarification as this mandatory transition from the LTHHCP to MLTC begins.