Managed Long-Term Care (MLTC) Plans

Beginning December 1, 2020, consumers who enroll in a Partial MLTC plan are allowed to switch plans for a 90 day grace period. After 90 days, they cannot switch plans for 9 months except for what is considered “good cause“. This “Lock-In” does not affect consumers that wish to enroll in a PACE or MAP plan and these plans do not have a “lock-in” period.

If someone needs assistance with selecting a plan, they can call us direclty (212) 540-2984.

  • Varieties of Managed Long-Term Care Plans

    MLTC plans solely manage a portion of a member’s Medicaid benefits while leaving the remainder as “straight/non-managed” Medicaid. This type does not affect a member’s Medicare benefits. Conversely, PACE and MAP plans oversee all member benefits for both Medicare and Medicaid.

  • Partial MLTC Plans

    Under Partial MLTC plans, the responsibility of administering specific Medicaid benefits falls on the plan’s shoulders, while the rest of the member’s benefits remain under “straight/non-managed” Medicaid. The Medicare benefits of a member remain unaffected if they are in the “straight/non-managed” category.

    Partial MLTC plans manage the subsequent Medicaid benefits:

    • Home Care
    • Adult Day Care
    • Medical Equipment
    • Ambulette transportation to doctor offices and clinics
    • Outpatient physical, occupational, and speech therapy
    • Audiology – including hearing aids and batteries
    • Optometry – including eyeglasses
    • Podiatry
    • Dental
      Meals
    • Personal Emergency Response System (PERS)
    • Nursing home care (applicable to entitled members)

     

    The ensuing Medicaid benefits continue to be under “straight/non-managed” Medicaid:

    • All doctors, excluding the four mentioned above
    • All hospital care – inpatient, outpatient, and emergency room
    • Outpatient clinics
    • Lab tests
    • Radiology tests
    • Prescription drugs
    • Mental health care
    • Assisted living
    • Hospice

     

    Crucially, it should be noted that Medicare remains the primary health insurance for those opting for Partial MLTC plans. Medicaid functions as a supplementary resource to bridge gaps in Medicare coverage.

    Enrolling in a Partial MLTC plan permits access to long-term care services while leaving most other medical care coverage unaffected. The enrollment does not necessitate the member’s primary care physician (and most specialists) to be in network with their MLTC plan. Furthermore, they are free to choose any hospital that accepts Medicare and acquire radiology and lab tests from providers who accept Medicare.

    Individuals must be at least 18 years old to be eligible for enrollment in a Partial MLTC plan.

  • PACE (Programs of All-Inclusive Care for the Elderly)

    PACE plans assume the management of all member benefits for both Medicare and Medicaid. Consequently, members generally receive services solely from in-network providers. Plans establish their own “adult day centers,” where primary care appointments and other services are offered to members. The center also serves as a venue for members to engage in social activities with fellow plan participants.

    Remarkably, only two PACE plans are available in New York City.

    Individuals must be at least 55 years old to be eligible for enrollment in a PACE plan, as indicated by the term “care for the elderly” in the program name.

  • MAP (Medicaid Advantage Plus)

    MAP plans manage all benefits for both Medicare and Medicaid, leading to services predominantly being accessible via in-network providers.

    Eligibility for enrollment in a MAP plan requires individuals to be at least 18 years old.

  • Enrolling in a Managed Long-Term Care Plan

    Individuals desiring enrollment in an MLTC plan are required to go through a two-step procedure. First, they must undergo a nurse’s assessment administered by the Conflict-Free Evaluation and Enrollment Center (CFEEC). Managed by Maximus, NY State’s vendor also known as NY Medicaid Choice, the assessment aims to verify the individual’s need for long-term care.

    Once Maximus sanctions a patient for MLTC enrollment, the patient can opt for their preferred MLTC plan. Subsequently, the selected MLTC plan sends a nurse for an independent evaluation. Following this assessment, the plan completes their own evaluation, culminating in the patient’s enrollment into the MLTC plan.

    Enrollments take place monthly on the first day of the month. While the aim is for assessments and paperwork to be completed by the 20th of a given month to ensure enrollment for the subsequent month, logistical factors can sometimes lead to deviations from this ideal timeframe. In practical terms, if all requirements are met by the 20th of a month, enrollment for the following month is feasible. To bolster the likelihood of timely enrollment, initiating assessments earlier in the month is advisable.

  • Making Changes in Managed Long-Term Care

    Beginning December 1, 2020, consumers who enroll in a Partial MLTC plan are allowed to switch plans for a 90 day grace period. After 90 days, they cannot switch plans for 9 months except for what is considered “good cause“. This “Lock-In” does not affect consumers that wish to enroll in a PACE or MAP plan and these plans do not have a “lock-in” period.

    Changes in MLTC plans are made on a monthly basis and are effective on the first of the month. The process of making a change is as follows:

    A consumer may contact any plan and request to switch to that plan. The enrolling MLTC plan will then send a nurse to evaluate the potential member. During the evaluation, the evaluating nurse will call NY Medicaid Choice together with the enrolling member to receive approval for the switch. After the evaluation, the enrolling plan will submit necessary enrollment paperwork to NY Medicaid Choice, who will approve and complete the enrollment. If someone needs assistance with selecting a plan, they can call us direclty (212) 540-2984.

    TIP: If a consumer is happy with the licensed home care services agency (LHCSA) that is sending the home health aide or personal care aide, or the CDPAP Fiscal Intermediary (FI) that is providing their CDPAP services, they can call the LHCSA or CDPAP FI directly and ask for their assistance in switching to a plan with whom they are contracted. This will help ensure that they remain the provider for the home attendant once the change is made.

    Similar to new enrollments, ostensibly, a change can be effective for the coming month if everything is completed by the 20th of the previous month. Here too, this is not always the case in reality. If someone is hoping to change plans for the coming month, having their assessment completed earlier in the month can enhance their chances of the change going through.

    It is important to be aware that just because a plan sends a nurse to evaluate you to switch to them, that does not obligate you to go through with the change. If you are not satisfied with the services being offered by the new plan, you may choose to decline the change.