CMS Approves State Waiver Amendment

In a letter dated Dec. 19, 2019, the Centers for Medicare and Medicaid Services (CMS) notified the State that it has approved the proposed amendment to the State’s Medicaid 1115(a) waiver that limits the partially capitated Managed Long Term Care (MLTC) plan nursing home benefit to three months for individuals who are designated as long-stay residents. Under the State’s proposal, such members would need to be disenrolled from Medicaid managed care and revert to fee-for-service (FFS) Medicaid after a three-month period. Additionally, individuals entering nursing homes for Medicaid-funded long stays would no longer be mandated to enroll into MLTC and would remain in FFS Medicaid.

This provision was enacted in the 2018-19 State Budget and has been the subject of lengthy negotiations between the State and CMS. While the Department of Health (DOH) has been preparing for the change in anticipation of CMS approval, the requirement to notify MLTC members of benefit changes and other implementation details will likely mean that the shift of existing long-stay residents back to FFS may not begin immediately.

We anticipate that DOH will soon provide additional information and guidance as to the timing and procedures for implementing this change. However, both nursing homes and MLTC plans should be monitoring for any potential payment or eligibility issues that may arise. Please let us know if you identify concerns as the process unfolds.

The approval also covers the State’s proposal to align the MLTC enrollment lock-in policy with that of Mainstream Medicaid managed care. Once effective, the policy will restrict the ability of members to transfer from one partially capitated MLTC plan to another without good cause.

In response to public comments received on the proposals, CMS notes that it worked closely with state and federal partners and other interested parties to minimize risk to beneficiaries impacted by the changes. While implementation details of both provisions will depend on DOH policy and guidance, the descriptions of the approved modifications as contained in the CMS letter are copied below.

Modification #1

Limit the nursing home benefit in the partially capitated MLTC plans to three months for enrollees who have been designated as long-term nursing home stays (LTNHS) in a skilled nursing or residential health care facility (nursing home). Afterwards, the individual will be involuntarily disenrolled from the partially capitated MLTC with coverage for nursing home services in the same facility provided by Medicaid fee for service (FFS), as long as the individual qualifies for institutional Medicaid coverage. Institutional eligibility is required for individuals in MLTC plans or in Medicaid FFS. Enrollees who are involuntarily disenrolled from a plan because they have reached the three month nursing home benefit limit in their plan will have the same due process rights as individuals who are involuntarily disenrolled from the plan for other reasons.

The state's contracted agency will determine if the plan's involuntary disenrollment request is appropriate and notice the consumer of the prospective disenrollment date if the disenrollment is approved. If the enrollee is dissatisfied with the disenrollment determination, they may challenge the determination through the fair hearing process. If successful, nursing home residents will be allowed to re-enroll in an MLTC and return to the community without requiring a Conflict Free evaluation and enrollment assessment, if such movement is within 6 months of the resident's disenrollment from the plan. In addition, individuals who are dually eligible for both Medicare and Medicaid, who are 21 years of age or older, and LTNHS will be excluded from joining MLTC plans. Eligible individuals will remain in FFS to access the long-term nursing home benefit and other necessary Medicaid funded services.

Modification #2

Aligns the lock-in policy of MLTC plans with MMMC. After this policy goes into effect, mandated enrollees of partially capitated MLTC plans will be limited in their ability to transfer to another MLTC partial capitation plan for 12 months from the effective date of enrollment. Enrollees may transfer to another partially capitated plan without cause during the first 90 days of the 12-month period. Regardless of whether they transfer to another plan, after the first 90 days the enrollee may not transfer to another partial capitation plan unless there is good cause to do so. Enrollees will receive notice of this change and a list of good cause reasons. These reasons may include moving away from the service area, inability of the plan to provide appropriate and accessible services and/or supports, poor quality care, lack of access to providers experienced in caring for the individual and a determination that the enrollment was non-consensual.

LeadingAge NY Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841