MLTC Partial Plan Additional Rate Codes Letter

December 9, 2013

All Partially Capitated Managed Long Term Care Plans currently operating in the Mandatory County of New York:

Rate codes 3479 and 3480 have been added to your provider profile and are retroactive to 7/1/12.

These rates were added as the result of a collaborative effort between the Plans and the New York State Department of Health to define clients targeted for mandatory enrollment in MLTC pursuant to the State's approved waiver with CMS.

The rate codes apply to dual eligible Medicaid recipients, age 21 and over who were mandated to join an MLTC Plan on or after 7/1/12 and had a previous history of 120+ days of community based long term care.

The two new codes are available for capitation billings effective 7/1/12. The codes are limited to those clients who meet the definition of mandatory enrollment into the MLTC program. Claims will be monitored to verify the eligibility criteria have been met. Within the targeted population, determination of which of the two codes to use will be decided by the member's initial SAAM score through September 2013 and the UAS score from October 2013.

Rate Code 3479 (New NHC Enrollees 21+ (Duals Only) are defined as those dually eligible members 21 years of age or older enrolled in the MLTC on or after July 1, 2012, who previously received personal care services on a fee-for-service basis and meet nursing home level of care criteria (having a SAAM/UAS score of 5 or more); and
Rate Code 3480 (New Non-NHC Enrollees 21+ (Duals Only) are defined as those dually eligible members 21years of age or older enrolled in the MLTC on or after July 1, 2012, who previously received personal care services on a fee-for-service basis and do not meet nursing home level of care criteria (having a SAAM/UAS score of less than 5).

The use of new rate codes will be phased in geographically in accordance with the CMS approved waiver phase-in plan. The NYSDOH will continue to notify Plans through the current rate development process as premiums are developed throughout the phase-in.

Previously paid capitation claims that will be submitted for adjustments must be submitted by January 31, 2014 and follow the correct procedure for submitting an adjusted claim to eMedNY. Adjusted claims must contain a delay reason code to prevent the adjustment from a system edit that will deny the claim for timely filing. Delay reason code 11 should be used on adjusted claims being submitted for either rate code 3479 or 3480. The eMedNY website at: https://www.emedny.org/info/TimelyBillingInformation.index.aspx contains a comprehensive guide to all information pertaining to timely filing. It is an important website to review.

Should you require assistance for submitting an adjusted claim, please call eMedNY at 800-522-5518 (choose option 3, then 4. You will need your MMIS provider ID number to obtain assistance).

Sincerely

Margaret O. Willard
Director, Bureau of Managed Long Term Care
Bureau of Managed Long Term Care
Office of Health Insurance Programs

James M. DeMatteo
Principle Healthcare Management Systems Analyst
Division of Finance and Rate Setting
Office of Health Insurance Programs