DAL on Social Adult Day Program, Marketing Violations and MLTC Enrollment

DOH issued a Dear Administrator Letter (DAL) to clarify the appropriate use of social adult day programs and enrollment of non-medically eligible individuals into MLTCs. As previously reported, DOH issued MLTC Policy 13:03 Community Based Long Term Care Services, which stated social adult day programs can contribute to the plan of care, but cannot be the primary service provided to an MLTC member.

The DAL states MLTC plans should not enroll a recipient in social day care unless the recipient has a functional or clinical need for Community Based Long Term Care Services (CBLTCS). According to DOH, CBLTCS include: personal care; home health care; private duty nursing; consumer directed personal assistance program; and adult day health care. The letter states that if a member who no longer demonstrates a functional or clinical need for CBLTCS, the recipient must be disenrolled from their MLTC plan. DOH is mandating that all MLTC plans reassess any member currently receiving social day care as a plan benefit.

The letter also mentions that OMIG will conduct audits on all enrollments per the OMIG work plan and DOH will recoup any capitation payment made for non-eligible members.

The DAL addresses reports of marketing violations and states MLTC plans and providers of plan services may not offer materials, financial gain or service incentives to recipients as an inducement to enroll in a MLTC plan or to transfer MLTC plans. In regard to social adult day programs - no MLTC marketing activities should be conducted at any social day care site and plans should not accept referrals from a social day care site. It refers back to an earlier policy -MLTC Policy 13.06: Marketing Guidelines for Managed Long Term Care Plans and Medical Service Providers.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871