Overview of Managed Long Term Care (MLTC)

MLTC Overview:

Managed Long Term Care (MLTC) is a system that streamlines the delivery of long term services to people who are chronically ill or disabled and who wish to stay in their homes and communities.

MLTC plans help provide these community based long term services and supports (CBLTSS) to people with chronic health conditions or disabilities. These services, such as personal care services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), are provided through MLTC plans that are approved by the New York State Department of Health (NYSDOH).

Transition Status:

Mandatory MLTC began in September 2012 and the transition was complete in July 2015.

Eligibility for MLTC:

Dual eligible individuals (having both Medicare and Medicaid), who are age 21 and older, not excluded per table 1 and who are assessed as needing community based long term care services for more than 120 days must enroll in MLTC in order to receive those services.

Nursing Home Requirement

With federal approval, the State amended the Medicaid Redesign Team (MRT) 1115 Demonstration Waiver to implement changes authorized in State Law. These changes became effective in 2020 and they included limiting the nursing home benefit in Partial Capitation plans to three months for those enrollees who are designated as long term nursing home stay (LTNHS). Members enrolled in Partial Capitation plans who have reached their three month nursing home limit and have no discharge plan, will be disenrolled to fee-for-service (FFS), provided they have been determined financially eligible for Medicaid coverage of nursing home care.

The following may voluntarily enroll in MLTC:

1. dual eligible individuals, age 18-20, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for more than 120 days; and
2. non-dual eligible individuals, age 18 and older, who have been assessed as eligible for nursing home level of care at time of enrollment and also assessed as needing community based long term care services for more than 120 days.

Eligibility Requirements:

An individual must be:

• determined eligible for Medicaid by the Local Departments of Social Services or entity designated by the Department;
• determined eligible for MLTC by the New York Independent Assessor Program using the Community Health Assessment (CHA) in the Uniform Assessment System (UAS-NY) eligibility assessment tool;
• capable, at the time of enrollment, of returning to or remaining in their home and community without jeopardy to their health and safety, based upon criteria provided by the Department; and
• expected to require at least one* of the following services covered by the MLTC Plan for more than 120 days from the effective date of enrollment:
  • nursing services in the home;
  • therapies in the home;
  • home health aide services;
  • personal care services in the home;
  • adult day health care;
  • private duty nursing; or
  • Consumer Directed Personal Assistance Services.
• The potential that an Applicant may require acute hospital inpatient services or nursing home placement during such 120 day period shall not be taken into consideration by the Contractor when assessing an Applicant's eligibility for enrollment.

* Members assessed as only needing lower level (L 1) services do not qualify for MLTC per MLTC Policy 13.21.

Populations Excluded and Exempt from Enrollment (Table 1):

Population	MLTC Excluded	MLTC Exempt	Notes (Information in this chart is current as of 4/2023)
Residents of psychiatric facilities	X
Individuals expected to be Medicaid eligible for less than six (6) months	X
Individuals eligible for Medicaid benefits only with respect to tuberculosis–relate services	X
Individuals with a "county of fiscal responsibility" code of 78 (New York State of Health) or 99 (i.e., eligible only for breast and cervical cancer services) in eMedNY	X
Individuals receiving hospice services at the time of enrollment	X
Individuals with a "county of fiscal responsibility" code of 97 (i.e., residing in a state Office of Mental Health (OMH) facility) in eMedNY	X
Individuals with a "county of fiscal responsibility" code of 98 (i.e., individuals in an Office for People with Developmental Disabilities (OPWDD) facility or treatment center) in eMedNY	X		MAP -excluded until program features are approved by the State and operational at the local district level to permit these individuals to voluntarily enroll in MAP
Individuals eligible for the family planning expansion program	X
Individuals under sixty–five (65) years of age in the Centers for Disease Control and Prevention breast and/or cervical cancer early detection program and need treatment for breast or cervical cancer, and are not otherwise covered under creditable health coverage	X
Residents of intermediate care facilities for the developmentally disabled (ICF/DD)	X
Individuals who could otherwise reside in an ICF/DD, but choose not to do so	X
Residents of alcohol/substance use disorder long term residential treatment programs	X
Individuals eligible for Emergency Medicaid	X
Individuals in the OPWDD Home and Community Based Services section 1915(c) waiver program	X
Individuals in the following section 1915(c) waiver programs: Traumatic Brain Injury, and Nursing Home Transition & Diversion	X
Residents of Assisted Living Programs (ALP)	X
Individuals in receipt of Limited Licensed Home Care Services	X
Individuals in the Foster Care	X
Residents of skilled nursing or residential health care facilities with an active LTNHS designation are excluded from enrollment in a MLTC Partial Capitation plan	X
Individuals with private Long Term Care insurance	X
Individuals aged 18-21 who are nursing home certifiable and require a continuous period of more than 120 days of community based long term care services		X
Native Americans/Alaskan Natives		X
Individuals who are eligible for the Medicaid buy-in for the working disabled and are nursing home certifiable		X
Aliessa Court Ordered Individuals		X

Sources: 2017-2021 MLTC Model Contracts, 1115 Waiver, and NYS Partnership for Long Term Care

New Assessment for MLTC Services:

Chapter 56 of the Laws of 2020 authorized the Department of Health (Department) to contract with an entity to conduct an independent assessment process for individuals seeking Community Based Long Term Services and Supports (CBLTSS), including Personal Care Services (PCS) and Consumer Directed Personal Care Services (CDPAS or CDPC Program - CDPAP). Subsequently, New York's PCS and CDPAS regulations at 18 NYCRR 505.14 and 18 NYCRR 505.28, respectively, were amended to require that individuals seeking these services under the Medicaid State Plan must obtain an independent assessment and be evaluated and have a Medical Review and Practitioner's Order form completed by an independent clinician that does not have a prior relationship with the individual seeking services.

Effective May 2022, the Department has contracted with Maximus Health Services, Inc. (Maximus) to implement the New York Independent Assessor, which includes the independent assessment, independent practitioner panel and independent review panel processes, leveraging their existing Conflict Free Evaluation and Enrollment Center (CFEEC) infrastructure and experience.

The New York Independent Assessor conducts all initial assessments and all routine and non-routine reassessments for individuals seeking personal care and/or Consumer Directed Personal Assistance Services (CDPAS).

• The assessment process includes:
  • the Community Health Assessment (CHA) in the UAS-NY, New York's comprehensive assessment for State Plan CBLTSS, conducted by a Registered Nurse; and
  • a clinical exam, conducted by a clinician on an Independent Practitioner Panel (IPP) under the New York Independent Assessor; and
  • for high needs cases, defined as the first time, after the date of New York Independent Assessor implementation, the proposed plan of care includes services for more than 12 hours per day, on average, an Independent Review Panel (IRP) evaluation to ensure that the proposed Plan of Care developed by the Local Department of Social Services (LDSS) or the Medicaid Managed Care Organization (MMCO) is appropriate and reasonable to maintain the individual's safety in their home.

In addition to these changes, effective November 8, 2021, the regulations expanded the type of clinicians that may sign a Practitioner's Order for PCS/CDPAS and conduct a high-needs case review to include:

• Medical Doctors (MD);
• Doctors of Osteopathy (DO);
• Nurse Practitioners; and
• Physician or Specialist Assistants (PA)

As of November 8, 2021, the regulations also increased the length of time the CHA may be valid from six (6) months to up to twelve (12) months. However, individuals will continue to be reassessed upon a change in medical condition, upon release from institutional care, or upon their request (non-routine reassessments) and before their current assessment expires (routine reassessment).

Additional information about New York Independent Assessor can be found here.

• Managed Long Term Care MAP and Partial Plans are no longer permitted to enroll new individuals until the New York Independent Assessor has conducted an initial evaluation to determine CBLTSS eligibility.
• MLTC Plans will continue to be responsible for completing their own assessments which determine the plan of care using the Person Centered Planning Guidelines updated November 2022.
• This policy does not apply to individuals transferring from one plan to another.
• The New York Independent Assessor evaluates consumer's eligibility for one of the following MLTC products:
  • Partially Capitated Plans
  • Program of All-Inclusive Care for the Elderly (PACE)
  • Medicaid Advantage Plus (MAP)

Covered Services:

• The covered services provided by MLTC Plans must comply with all standards of the New York State Medicaid Plan established pursuant to Social Services Law (SSL) § 363-and satisfy all other applicable requirements of SSL and Public Health Law.
• See Appendix K of the MLTC Model Contracts for a complete list of Managed Long Term Care Covered/Non-covered Services.
• NYS Medicaid is the payer of last resort; all other coverage must be utilized before billing Medicaid.
• It is the Plan's responsibility to educate their providers not to bill for services, equipment, and/or supplies included in a rate paid to the facility.

As of Approved MLTC Model Contracts 2017-2021 and Amendments and 2022-2026 Model Contracts in Development
Services, When Provided, Would Be Covered by the Capitation1, 2
Services Provided as Medically Necessary:	Non-Covered Services; Excluded From The Capitation; Can Be Billed to Fee-For-Service or Can Be Billed to Medicare If Dually Enrolled.
Care Management	Inpatient Hospital Services
Nursing Home Care	Outpatient Hospital Services
Home Care Nursing Home Health Aide Physical Therapy (PT) Occupation al Therapy (OT) Speech Pathology (SP) Medical Social Services	Physician Services including services provided in an office setting, a clinic, a facility, or in the home.3
Adult Day Health Care	Laboratory Services
Personal Care	Radiology and Radioisotope Services
DME, including Medical/Surgical Supplies*	Emergency Transportation
Personal Emergency Response System	Rural Health Clinic Services
Non-emergent Transportation
Podiatry	Chronic Renal Dialysis
Dentistry
Optometry / Eyeglasses	OPWDD Services
PT, OT, SP or other therapies provided in a setting other than a home.	Family Planning Services
Audiology / Hearing Aids	Prescription and Non-Prescription Drugs, Compounded Prescriptions
Respiratory Therapy	Assisted Living Program
Nutrition	All other services listed in the Title XIX State Plan
Private Duty Nursing
Consumer Directed Personal Assistance Services
Mental Health (services are covered under the MAP plan 1/1/23)	Mental Health (services are billed FFS under the Partial Capitation and PACE plans) billing information can be found here
Alcohol and Substance Abuse Services (services are covered under the MAP plan 1/1/23)	Alcohol and Substance Abuse Services (services are billed FFS under the Partial Capitation and PACE plans)
Services Provided Through Care Management:
Home Delivered or Congregate Meals
Social Day Care
Social and Environmental Supports

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<sup>1. The capitation payment includes applicable Medicare coinsurance and deductibles for benefit package services.  1
2. Any of the services listed in this column, when provided in a diagnostic and treatment center, would be included in and covered by the capitation payment.  2
3. Includes nurse practitioners and physician assistants acting as "physician extenders".  3</sup>

* As outlined in the DME Manual found here.