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An Easy to Understand Guide on MLTC in New York

Thursday, November 26, 2020

If you’re a resident of New York, and you need long term care, then you might need to join a Managed Long Term Care (MLTC) plan.

 

Long term care can include things such as nursing home care, adult day cares, or a caregiver at home helping you with daily living activities like cleaning, bathing, grooming, etc.

 

In this guide, we will discuss all you need to know about MLTC plans in NY in a way that is easy to understand.

 

We’ll cover what is an MLTC plan, and describe each separate type of MLTC plan. We will also discuss who must join an MLTC, and how it may affect your enrollment in other programs like CDPAP.

 

If you fall under the category of people who must join an MLTC, we will also talk about how to sign up for one.

 

What is Managed Long Term Care (MLTC)?

 

MTLC is a health insurance system approved by the New York State Department of Health (NYSDOH) that delivers necessary care to those who need long term care.

 

Health insurance plans typically cover medical expenses like doctor’s visits, drug costs, and hospital stays.

 

But depending on your plan, many times they don’t cover long term care. And that’s where an MLTC plan can be helpful.

 

For example, if you have a disability and need ongoing physical therapy, or if you have an elderly family member in an adult day care or nursing home, an MLTC plan can help with the expenses.

 

Or perhaps you need assistance with various daily activities, and you've hired a family member as a care provider through CDPAP. In this case you may need to enroll in an MLTC as well.

 

 

One of the benefits of an MLTC plan is that, when you enroll, you get a Care Manager.

 

If you have any problems, issues, or questions on your coverage or care, you can always contact your care manager for help. They will also visit you a couple of times a year to check in on you and make sure everything is going well.

MLTC and Medicaid

 

As we mentioned in the previous section, health insurance often does not cover long term care. So, people that have nursing home or home care expenses often get it through Medicaid in New York.

 

And most NY Medicaid beneficiaries that receive long term care must get it through an MLTC program, as we will discuss below.

 

The NYSDOH approves MTLC plans to look for the best interest of consumers, but the premiums are paid for by NY state Medicaid.

 

Let’s say you have nursing home bills.

 

If you fall under a certain group of people, you’d enroll in an MLTC plan, which is a private health insurance plan approved by NYSDOH. The insurance provider will cover your nursing home expenses.

 

But you don’t have to pay the premium for the MLTC insurance plan, because that will be paid by Medicaid.

 

What kinds of MLTC plans are there?

 

There are five types of MLTC plans.

 

If you only have Medicaid and not Medicare:

 

●       Mainstream Medicaid Managed Care (MMC)

 

If you have both Medicaid and Medicare, but only plan on primarily using your MLTC plan for long term care:

 

●       Medicaid MLTC

 

If you have both Medicaid and Medicare, and plan on using your MLTC plan for comprehensive medical coverage:

 

●       Program of All-Inclusive Care for the Elderly (PACE)

●       Medicaid Advantage Plus (MAP)

●       Fully Integrated Duals Advantage (FIDA)

 

These three are often called “fully-capitated” plans, because once you enroll in them they cover both your Medicaid and Medicare benefits.

 

So you’d no longer need your Medicare card to receive care. Everything will be handled through your MLTC plan. But you do have to make sure that your doctors, hospitals, pharmacies, etc., accept your specific plan.

 

Let’s take a closer look at each type of MLTC and what they cover.

Mainstream Medicaid Managed Care (MMC)

 

If you only have Medicaid and not Medicare, and you need long term care, then you probably already get your coverage through a Medicaid Managed Care (MMC) plan.

 

An MMC plan will also cover your other medical expenses like doctor’s visits, medicines, hospital stays, and more. You most likely do not need to apply for a separate MLTC plan for long term care coverage.

 

All the rest of the MLTC plans on this list only apply to you if you have both Medicare and Medicaid.

Medicaid MLTC

 

This one is a “partial-capitation MLTC” because it only covers part of your total care expenses.

 

A Medicaid MLTC plan will only cover your long term care expenses. The rest of your medical expenses will continue to be covered by Medicare.

 

You will need to use both your Medicare card and your MLTC card on these plans.

 

For anything other than your long term care, you would continue seeing your current doctors and medical providers and nothing will change with your Medicare coverage.

 

The Medicaid MLTC will only cover any expenses related to the following:

 

●       Home care services (including CDPAP, see below)

●       Physical therapy

●       Occupational and speech therapy

●       Adult daycare

●       Medical supplies

●       Transportation to medical appointments

●       Nursing home expenses

●       Dental care

Program of All-Inclusive Care for the Elderly (PACE)

 

PACE plans offer the added convenience of having all of your services under one plan.

 

As we mentioned before, this is one of the “fully-capitated” plans, meaning one plan will manage both your Medicare and Medicaid benefits, including long term car, doctor visits, drug costs, and more.

 

The additional requirement to enroll in PACE is that you have to be 55 years of age and older, along with having both Medicare and Medicaid, and requiring long term care.

 

There is one caveat to PACE which could be good or bad depending on where you live. You can only go to a center in your area if you’re enrolled in PACE.

 

Your neighborhood PACE center will include all the doctors and nurses who will take care of all your needs. Some PACE centers may even include meals, adult day care, and other convenient services.

 

This is, of course, separate from any care you receive at home.

 

To find a list of PACE centers, or to see if you live close enough to one where you can qualify, contact NY Medicaid Choice and ask to speak with a counselor.

Medicaid Advantage Plus (MAP)

 

Just like PACE, MAP plans will cover your regular Medicaid, Medicare, as well as long term care expenses.

 

The requirements for age might vary between 18+ to 65+, depending on the specific plan. A counselor at NY Medicaid choice might be able to help you pick the right plan for you.

 

MAP is different from PACE in the sense that you don’t need to go to a specific center for your care.

 

Again, depending on where you live, that could be a benefit if there are no PACE centers in your neighborhood.

 

 

 

Fully Integrated Duals Advantage (FIDA)

 

A relatively newer type of MLTC plan, FIDA offers more control over your health choices.

 

Like PACE and MAP, FIDA is a “fully-capitated” plan, meaning it covers all your Medicaid, Medicare, and long term care expenses.

 

But with FIDA, you can be a part of a team that makes choices about your health care. In other words, you have more flexibility and options when it comes to the types of care and service you will receive.

 

You can include your doctor, family member, health care proxy, or even your MLTC care manager as a part of your health team.

 

Better coordination between all teams means that everyone is on the same page about your medical needs and preferences, and that the process is smooth when it comes to receiving care, billing, and more.

 

There can be additional services included in FIDA plans, including the following:

 

●       Home modifications to benefit your wellness

●       Non-medical transport

●       Doctors visits to your residence

●       Moving services out of nursing homes

●       OTC items at the drugstore

 

One thing to note is that FIDA is only available in the following areas in NY.

 

●       NYC

●       Nassau

●       Suffolk

●       Westchester

 

 

 

 

 

 

Who must join an MLTC plan?

 

There are some NY residents in need of long term care who must enroll in an MLTC plan.

 

If you currently receive long term care through Medicaid, then you might be already enrolled in an Mainstream Medicaid Managed Care (MMC) plan.

 

Contact the person or department that handles your coverage and ask them if you’re signed up for managed care, or if you need to enroll.

 

Otherwise, if you currently don't receive long term care, but you or a family member will need it in the future, then here are the requirements.

 

If you need to enroll in Medicaid first, so you can then get your long term care through an MLTC plan, then check out our list of best Medicaid plans in NYC.

 

If ALL of the following apply to you, then you must enroll in managed care.

 

●       You’re currently enrolled in Medicaid

●       You’re currently enrolled in Medicare

●       You’re in need of long term care (home care, adult day care, nursing home, etc.)

●       You’re 21 years of age or older

 

You can pick between a Medicaid MLTC, PACE, MAP or FIDA plan.

 

How do I sign up for an MLTC plan?

 

If you need to enroll in an MLTC plan, then the process would look like the following.

Step 1: Call New York Medicaid Choice

 

The first step for you would be to call New York Medicaid Choice, a state program that helps with managed care enrollment.

 

Website: www.nymedicaidchoice.com

 

Tel: 855-222-8350

 

You’ll be connected with a counselor who can help you choose a program and answer any questions.

 

Once you decide on an MLTC plan that is right for you, then your counselor will get the evaluation process started.

 

They will arrange an evaluation of your case through the Conflict-Free Evaluation

and Enrollment Center (CFEEC).

 

You don’t need a referral from your doctor to schedule a CFEEC evaluation.

 

You will be asked to provide your name, date of birth, address, SSN, or Medicaid ID during the call.

Step 2: CFEEC (Conflict-Free Evaluation and Enrollment Center) evaluation

 

Conflict-Free Evaluation and Enrollment Center (CFEEC) is a program run by the New York state Medicaid program. Their purpose is to evaluate whether you’re in need of long term care and whether you need to enroll in an MLTC plan.

 

They’re called conflict free because CFEEC is not affiliated with any of the private insurance providers that offer MLTC plans. But they can still assist you in picking an MLTC plan that is right for you.

 

You will need a new evaluation if this is your first time joining an MLTC plan, or if it has been more than 45 days since you were last enrolled in a plan. If your old evaluation has expired, then you will also need to schedule a new one.

 

How does the CFEEC evaluation process work?

 

Once you schedule an evaluation, the CFEEC will send a registered nurse to your home. The nurse will examine you to evaluate whether you need long term care.

 

If you currently have any other health insurance, you should have that information available. If you’ve already applied for Medicaid, but you’re waiting on the card, you should let the nurse know about that as well.

 

During the evaluation, the nurse may ask you various questions about your disability or other medical conditions. For example, they might ask you about the following, among other things.

 

●       If you’re able to walk without assistance

●       If you can clean, bathe, and groom yourself without any trouble

●       If someone currently has to help you with grocery shopping and meal preparation

●       If you have a disability that requires ongoing physical therapy

●       If you’re considering moving to a nursing home or another long term care facility

 

After the evaluation, the nurse will decide whether you need long term care through an MLTC plan, and he or she will inform you about the decision.

 

You will also receive a written copy of the decision by mail.

Signing up for CDPAP

 

If you’re already enrolled in CDPAP, or you’re considering applying for CDPAP, let’s discuss how an MLTC plan may affect your CDPAP benefits.

 

But in case you’re not familiar with CDPAP, let’s take a brief look at what it is.

 

What is CDPAP?

 

The Consumer Directed Personal Assistance Program (CDPAP) is a NY Medicaid program designed to give care recipients (and providers) more control over their own care.

 

In many cases, Medicaid beneficiaries who need home care must get it from a care provider who works for an approved agency.

 

But through CDPAP, you can pick your own caregiver. So, you can hire friends, family members (with a few exceptions), or anyone else you feel comfortable receiving care from.

 

You and your caregiver get to decide the level of care that is best for you. But one of the requirements of CDPAP is that you (or an appointed family member) must be able to hire, train, and direct your aide on your needs.

 

For many people with disabilities, it is a significant benefit to be able to continue living in their own communities instead of a nursing home.

 

The best part is that the aide gets compensated through Medicaid for their efforts.

 

For more info, including eligibility requirements, what’s covered, how it works, and how to apply, check out our CDPAP guide.

 

Can you sign up for CDPAP on an MLTC plan?

 

If you qualify for CDPAP, then you must be able to enroll (or continue to use) in CDPAP though an MLTC plan.

 

When you enroll in a managed care plan, you must let your care provider know that you want to coordinate your care through CDPAP. If you can’t direct your care, you can still sign up for CDPAP as long as you can appoint a family member to coordinate care on your behalf.

 

Your provider will then assess whether you, or your appointed family member, can adequately plan and direct your care. If the evaluation is satisfactory, then they will approve your enrollment in CDPAP.

 

If your CDPAP participation is denied, then you can file an appeal to challenge the decision.

 

Appealing your MLTC plan’s CDPAP decision

 

Whether it’s for CDPAP, or any other decision by your MLTC provider that you disagree with, you can file an appeal.

 

By filing an appeal, you’re formally requesting that the provider reconsider their decision to deny, reduce, or end any benefits that you feel you’re entitled to receive.

 

If you’re denied coverage by your MLTC, your notice will include instructions on how to appeal the decision in written form. Or you can also file an appeal orally.

 

You can file an appeal in two different ways. Standard Appeal and Fair Hearing.

 

Filing a standard appeal

 

You can file a standard appeal within 45 days of receiving the decision that your CDPAP coverage was denied.

 

All you need to do is call the number on your MLTC card, and ask to be transferred to the Appeals and Grievances Department.

 

Or you can also get in touch with your MLTC care manager and let them know that you want to file an appeal.

 

Filing a Fair Hearing appeal

 

You can also file an appeal directly with the state of NY instead of your MLTC plan, if you feel like your coverage for CDPAP (or another service) was incorrectly denied by your MLTC provider.

 

This type of appeal is known as the Fair Hearing appeal. You would explain your case and appeal to a state-appointed judge, also known as an Administrative

Law Judge (ALJ).

 

Here are a few ways to file a Fair Hearing appeal.

 

In-person: You can file an appeal at your local Medicaid office.

 

By phone: 800-342-3334

 

Online: https://otda.ny.gov/hearings/request/#online

 

By mail: Download the form, fill it out, and mail it to this address.

 

The New York State Office of Temporary and Disability Assistance

Office of Administrative Hearings

P.O. Box 1930, Albany, New York 12201-1930.

 

Can you have assets and join an MLTC?

 

Your asset requirements to join an MLTC plan will depend on which factors make you eligible for a managed care plan. See the section above on who has to join an MLTC for the details.

 

Most likely, to be eligible for an MLTC, you’ll also need to be eligible for Medicaid in NY.

 

While you can have some assets and still be eligible for Medicaid, there are some limitations on the resources you can own.

 

But the good news is that even if you own more assets than the eligibility limit, there are ways you can still qualify for Medicaid and long term care through an MLTC.

 

For more details on assets and eligibility, as well as what to do if you have too many assets, check out our guide on Medicaid spend down.

How do I change my MLTC?

 

You are allowed to change your MLTC plan any time you need. All you need to do is contact the plan you wish to join.

 

If you’re not sure which plan is best for you, or if you switch to another plan for better coverage, you can always contact New York Medicaid Choice.

 

Even if you decide to switch, your current plan must continue covering you still the switch is complete, usually at the end of the month.

The bottom line

 

If you’re a New York resident who needs long term care, and you have to get it through Medicaid, then you might need to sign up with an MLTC plan.

 

Refer to the section above to see if you fall under any of the categories that might require you to sign up for a managed care plan.

 

The type of MLTC plan that is right for you will depend on your specific needs. It will also depend on whether you have only Medicaid, or both Medicaid and Medicare.

 

Remember, your CFEEC counselor can also help you pick the MLTC plan that is right for you.

 

And if you’re interested in having more control over your own care, and want to be able to hire your own care provider, be sure to check out CDPAP (which is also covered by MLTC plans).