New MLTC Rate Codes for Mandatory Enrollment

In a letter dated Aug. 11, 2014, the Department of Health (DOH) has issued guidance on two new rate codes, #3479 and #3480, applicable to claims for individuals who meet the definition of mandatory enrollment in a Managed Long Term Care (MLTC) plan.  These rate codes apply specifically to dual eligible Medicaid recipients, age 21 and over.

DOH defines the codes as follows:

Rate Code 3479 - New NHC Enrollees 21+ (Duals Only) are defined as those dually eligible members 21 years of age or older enrolled in an MLTC on or after July 1, 2012, who previously received personal care services on a fee-for-service basis and meet the nursing home level of care criteria (having as SAAM/UAS score of 5 or more).

Rate Code 3480 – New Non-NHC Enrollees 21+ (Duals Only) are defined as those dually eligible members 21 years of age or older enrolled in the MLTC on or after July 1, 2012, who previously received personal care services on a fee-for-service basis and do not meet the nursing home level of care criteria (having a SAAM/UAS score of less than 5).

The DOH letter provides specific guidance on the rebilling process, including specification on the effective dates per geographic location and level of service.  Previously paid capitation claims for mandatory enrollment for periods prior to the date of the DOH letter that will be submitted for adjustment must be submitted no later than Sept. 30, 2014 according to the specified procedure.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827