GIS 14 MA/010:06 to 30 Conversion for MLTC Enrollees

As a component of the continuing state-wide Medicaid Redesign Initiative, individuals requiring more than 120 days of community based long term care services (CBLTCS) must receive those services through enrollment in a Managed Long Term Care Plan (MLTCP). CBLTCS include personal care, consumer directed personal care, home health care, services provided by a Certified Home Health Agency, Adult Day Health Care, private duty nursing, and services provided through a Long Term Home Health Care Program (LTHHCP).

Recipients with 06 Provisional Coverage requiring or receiving the services noted above must enroll in a MLTCP. Currently, 06 Provisional Coverage is not compatible with MLTCP enrollment and a 06 Provisional recipient cannot immediately convert to a Medicaid coverage type that is compatible with enrollment into a MLTCP. The current process of changing the coverage code is labor intensive and requires a manual change to the case file at the LDSS level. To effectuate immediate MLTC enrollment for 06 Provisional recipients, modifications have been made to the WMS Prepaid Capitation Plan subsystem.

Effective April 28, 2014, for 06 Provisional Coverage cases that are requesting enrollment into a partially capitated MLTC Plan and have an RVI Indicator of 1, 2, or 4, WMS will allow input of a PCP subsystem entry indicating enrollment into a specific partially capitated MLTCP. Input of the enrollment line in the PCP subsystem (WMS) will trigger a conversion of the 06 Provisional Coverage Code to a Coverage Code of 30 PCP - Full Benefits Coverage.

A recipient with 06 Provisional Coverage requesting enrollment into a partially capitated MLTCP will meet the spenddown requirement of an incurred medical expense on the first day of each month enrolled in the MLTCP. The spenddown liability is the MLTCP's responsibility as the monthly PCP capitation rate is established net of spenddown. As the excess income is owed to the MLTCP each month and collection of the incurred spenddown is the MLTCP's responsibility, the consumer's Medicaid Coverage Code may be converted from 06 to 30. For these recipients the Excess Income will be included on the monthly Roster, the Interim Report and the Secondary Roster for each Managed Long Term Care Plan.

When a Managed Long Term Care Plan enrollment is ended, with no new enrollment, the recipient Medicaid Coverage Code will revert back to 06 Provisional Coverage. The Excess Income Amount will no longer be included on the Primary Roster, The Interim Report, and the Secondary Roster.

The 06 to 30 conversion is operational for enrollments into a partially capitated MLTC Plan; the conversion is not operational for enrollments into Medicaid Advantage Plus (MAP) Plans or PACE Plans.

Please submit any questions to the Managed Long Term Care Bureau Systems Mailbox at mltcsys@health.state.ny.us.