Long Term Home Health Program (LTHHCP) Clarification

February 7, 2012

As part of the Medicaid Redesign Team proposal #90, questions have arisen about the role of the long term home health care program now and in future. This document is intended to provide guidance to existing long term home health care providers as well as the health care community as a whole.

State law provides that Medicare/Medicaid dual eligible recipients, age 21 and older in need of community based long term care for more than 120 days, will be required to enroll in a Managed Long Term Care Plan (MLTCP) including Partially Capitated Managed LTC, Program of All- Inclusive Care for the Elderly (PACE), or Medicaid Advantage Plus (MAP), or a Care Coordination Model (CCM). In addition, non-duals currently in exempt or excluded categories, including those in a LTHHCP not pursuing CCM or MLTC designation, are being enrolled in Medicaid Managed Care. Mandatory enrollment will not begin until the Department receives CMS approval. The exact schedule and timeline will be released once the Department receives final approval.

What is the current plan for enrollment of LTHHCP participants in managed long term care and Medicaid managed care?

The draft enrollment plan before CMS indicates that LTHHCP participants that are dually eligible for Medicaid and Medicare will enroll in a MLTC on a geographically phased basis beginning with New York City residents in November 2012. Residents of the remaining counties will be enrolled dependent on MLTC capacity to assure consumer choice and continuity of care. LTHHCP participants that are non-duals (Medicaid only) will be required to enroll in Medicaid managed care organizations (MCOs) or MLTCs in those areas of the state where enrollment is mandatory. The exact schedule and timeline will be released once the Department receives final approval. There must be a contractual arrangement between the LTHHCP and MLTC/MCO for services to continue from the LTHHCP provider following plan enrollment. Additional information is available on the Medicaid Reform website at: http://www.health.ny.gov/health_care/medicaid/redesign/.

How will LTHHCP participants be notified?

LTHHCP participants will be notified by the state or its contractor via a letter mailed to their homes within the time frames approved by CMS. That approval is pending at this time and the Department will provide the specific dates when available.

How will continuity of care be provided for LTHHCP in this MCO/MLTC enrollment process?

What is the role of the LTHHCP agency for enrolling LTHHCP participants to managed care?

What is the role of the LTHHCP agency for enrolling LTHHCP participants to managed care?

LTHHCPs not developing their own MLTC, CCM or MCO may seek to contract with a plan or CCM. This would enable the LTHHCPs to continue providing needed services to current participants. As the time for enrollment in managed care approaches, LTHHCP participants will be notified that they must choose a MCO, a Managed Long Term Care Plan (MLTCP) or a Care Coordination Model (CCM). LTHHCP agency staff will assist participants with plan enrollment to ensure continuity of care.

What options do LTHHCPs have to continue as providers within the managed care environment?

One option for entities such as the LTHHCPs is to establish a corporate entity to apply to be a MLTCP or CCM.

Another option is that LTHHCPs, consistent with any arrangement or agreement with their sponsoring agency, may make contractual arrangements with MCOs, MLTCPs or CCMs to provide home care services.

With regard to delineation of care management responsibilities in cases of LTHHCP contracts with MLTCs, MCOs or CCMs, it should be noted that currently LTHHCPs, MCOs, MLTCPs and CCMs all have broad care management responsibilities. Accordingly, contractual arrangements must clearly articulate case management responsibilities between the entities to ensure no duplication of case management services.

It should be noted that once a LTHHCP participant is transferred to a MLTCP or a CCM, the payment from the state will take the form of a "per member per month" payment to the plan for both services and care coordination. MLTCPs and CCMs may contract with providers for reimbursement, services and care coordination but the provider will no longer bill the state. All payment will be pursuant to the contractual relationship between the plan and the provider.

How does a LTHHCP apply to become a MLTCP?

A LTHHCP would need to set up a separate corporate entity to apply to be a MLTCP. LTHHCPs also have the option to group together to form a separate, umbrella corporation that could sponsor the MLTC under which the LTHHCPs could contact to provide their services. Applications are posted on the DOH website at: http://health.ny.gov/facilities/long_term_care/managed_long_term_care.htm

What are the basic elements of MLTC approval?

Applications will be reviewed for the following:

  • Proof of adequate legal and financial structure
  • Identification of service geographic area and target population (including any special populations)
  • Character and competence review
  • Contracted network review
  • Description of care management model and grievance system
  • Demonstration of financial capability and capitalization

Where can questions about MLTC applications be submitted?

Questions about applications should be submitted to: MLTCAPPS@health.ny.gov

What is a Care Coordination Model?

The Care Coordination Model (CCM) is a managed long term care option similar to a MLTCP. The benefit package includes both community-based and institutional Medicaid covered long term care services. Five services (dentistry, audiology/hearing aids, vision/eyeglasses, outpatient therapies and podiatry) are not required to be in the benefit package until Year 2 of operation. Care management is a key function of the CCM-providers must ensure that individualized, person-centered care management is provided to all members. A CCM also has two years to phase-in to the MLTCP reserve requirements.

What are the basic elements of CCM approval?

Entities applying to become a CCM must meet the same basic requirements as a MLTCP with the two exceptions noted above. CCM principles and guidelines specified by the Commissioner of Health are posted on the DOH website at: http://www.health.ny.gov/health_care/medicaid/redesign/managed_ltc_workgroup.htm

How does an entity apply to become a CCM provider?

The CCM application is posted to DOH website: http://www.health.ny.gov/facilities/long_term_care/managed_long_term_care.htm

Where can questions about CCM applications be submitted?

Questions about CCM application should be directed to: MLTCAPPS@health.ny.gov

What are Health Home Services?

Medicaid Health Homes (HH) offer a comprehensive care program for recipients who have complex medical, behavioral, and social services needs. The program is intended to reduce the number of avoidable hospitalizations and visits to emergency rooms. Services will include: comprehensive care management; care coordination and health promotion; transitional care, including follow-up care when a patient leaves an inpatient setting; patient and family support; referral to community and social support services; and the use of health information technology to link services. Each enrolled patient will be assigned a single care manager responsible for the overall management and coordination of the patient´ care.

What entities are approvable HH providers?

Eligible providers include managed care plans; hospitals; medical, mental and chemical dependency treatment clinics; federally qualified health centers (FQHCs); targeted case management programs; primary care practitioners; patient-centered medical homes; and other Medicaid enrolled entities.

May a LTHHCP contract with a HH?

A LTHHCP, consistent with any arrangement or agreement with their sponsoring agency, may enter a contract with a HH. Interested agencies should visit the following DOH website for information on the different phases of HHs, including information on when long term care services will be included in HHs: http://www.health.ny.gov/health_care/medicaid/program/medicaid_health_homes/.