Long-Stay Residents Shift from MLTC to Fee-for-Service
The Department of Health (DOH) reports that the batch disenrollment of long-stay residents from partially capitated Managed Long Term Care (MLTC) plans was successfully accomplished and that these residents will be covered by fee-for-service (FFS) Medicaid effective Aug. 1st. Members will recall that this implements the next stage of the 2018-19 State Budget provision that limits members of partially capitated MLTC plans who are in a long-term nursing home stay to three months of MLTC enrollment. The Dear Administrator Letter (DAL) that DOH issued to nursing homes on June 11th outlining the process is available here.
The first phase of the process occurred earlier this year when new long-stay nursing home residents not yet enrolled in MLTC were no longer required to enroll. The Aug. 1st batch disenrollment represents the second phase. After the batch disenrollment, no further disenrollments will occur until such time as DOH issues guidance for the third phase (i.e., monthly plan-initiated disenrollments of residents newly meeting the three-month criteria).
Residents impacted by the batch disenrollment should have received two notices in July, including an option to request a fair hearing which would have stopped their disenrollment process. Please note that the change in the nursing home benefit does not apply to other MLTC products such as Programs of All-Inclusive Care for the Elderly (PACE) or Medicaid Advantage Plus (MAP), nor does it apply to mainstream Medicaid Managed Care. The change also does not impact rehabilitative, short-term, or temporary nursing home residents enrolled in MLTC.
We remind nursing home members that for new admissions and changes in status that occur following receipt of the DOH letter, homes are required to provide a copy of the LDSS-3559 to the resident and any other individual representing the resident in his or her care with the nursing home. The LDSS-3559 is also required to be sent by the nursing home to the resident’s local department of social services (LDSS).
While the batch disenrollment seems to have gone as planned, we have heard from both plans and providers that some residents that seem to meet the long-stay criteria were not disenrolled. We recommend that plans and providers review their rosters carefully to ensure that they accurately identify those residents who are reverting to FFS and bill/pay accordingly. If you observe discrepancies or encounter problems, please let us know.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841