More Nursing Home Residents to Revert to FFS
The Department of Health (DOH) is preparing to implement a second round of batch disenrollments of long-stay nursing home residents from partially capitated Managed Long Term Care (MLTC) plans on Nov. 1st. Unless he or she is working toward returning to the community or requests a fair hearing, a resident meeting the four criteria listed below will be transferred to Medicaid fee-for-service (FFS) on Nov. 1st:
- Resident is enrolled in a partially capitated MLTC plan;
- Resident’s status is identified as a long-term nursing home stay (LTNHS) (i.e., LDSS-3559 provided to resident and submitted to local department of social services (LDSS));
- Resident has been in a LTNHS for more than three months (LTNHS 3+); and
- Resident has been determined by the LDSS to be financially eligible for nursing home Medicaid coverage.
This additional “Batch Process” will disenroll the members who now meet the above criteria and were not included in the Aug. 1st disenrollment. The process will establish the required entries in the Principal Provider Subsystem in the Welfare Management System (WMS) to initiate Medicaid FFS coverage for these individuals and direct payment to the nursing home. The individual will subsequently appear on the nursing home’s monthly roster.
Members will recall that new long-stay nursing home residents are no longer required to enroll into MLTC and that enrollment in partially capitated MLTC plans is now limited to three months for nursing home residents after their designation as a LTNHS. The three-month benefit period begins on the first day of the month following the month of the effective date of the LTNHS designation documented by the nursing home, in conjunction with authorization by the MLTC plan, on the LDSS-3559, “Residential Health Care Facility Report of Medicaid Recipient Admission/Discharge/Readmission/Change in Status,” or an approved local equivalent. The change in the long-term nursing home care benefit has no impact on rehabilitative, short-term, or temporary nursing home residents and does not impact Program of All-Inclusive Care for the Elderly (PACE) participants, Medicaid Advantage Plus (MAP) members, or mainstream Medicaid managed care enrollees.
DOH is using the same plan member notices that were used for the August cycle. The change in benefit notice is here; the disenrollment notice is here. The Sept. 14th Dear Administrator Letter (DAL) outlining the process is available here. Please let us know if you encounter problems with the transition.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841