MLTC Policy 14.01

  • MLTC Policy 14.01: Transfers from Medicaid Managed Care to Managed Long Term Care (PDF, 392KB)

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 14.01: Transfers from Medicaid Managed Care to Managed Long Term Care

Date of Issuance: January 13, 2014

Effective immediately, non dually eligible individuals (individuals who have Medicaid but not Medicare coverage, i.e. Medicaid-only) enrolled in a Mainstream Managed Care Plan (MMCP) may disenroll from the MMCP and enroll into a Managed Long Term Care Plan (MLTCP) only if the member is in need of a service that cannot be provided in the MMCP, or if the member has become eligible for Medicare and meets the MLTCP enrollment criteria. There are three (3) services that are not currently available in MMCPs but are available in a MLTCP. These services are: home delivered or congregate meals; social day care services; and, social and environmental supports. For example, a Medicaid-only Managed Care enrollee who suffers a debilitating episode and now, in addition to community based long term care, requires a home delivered meals service may request disenrollment from the MMCP and enrollment into a MLTCP. The member must meet MLTCP enrollment criteria. If the member becomes eligible for Medicare and is receiving community based long term care services (CBLTCS), the MMCP must make diligent efforts to transition the member to the MMCP´s MLTC product to promote continuity of care, or direct the member to contact the State´s Enrollment Broker, New York Medicaid Choice (NYMC), to discuss enrollment into an alternative MLTCP, provided that the member meets MLTCP eligibility and enrollment criteria. MLTCP eligibility requires the non-dual member to meet Nursing Home Level of Care criteria.

Please note: MMCP members who become eligible for Medicare and are receiving CBLTCS must access those services from a MLTCP in districts that are mandatory for MLTCP being processed through NYMC. In non-mandatory districts, MMCP members receiving CBLTCS have the option of Fee-For- Service (FFS) or a MLTCP if available being processed through the Local District of Social Services (LDSS).

If a MMCP member requests disenrollment from a MMCP in order to transfer to a MLTCP, NYMC or LDSS must ask the member to provide evidence that the member is in need of one or more of the services listed above that cannot be provided by the MMCP or provide evidence that the member is a dual eligible and can meet the eligibility requirements for MLTCP enrollment.

If the non-dual member is in need of a benefit not included in the MMCP benefit package, a letter or referral from a practitioner for the requested service must be provided. If the non-dual member cannot provide evidence that he/she is in need of one or more of the services listed above, the non-dual member will be informed that he/she cannot transfer to a MLTCP and must remain in the MMCP. The non-dual member will receive a notice of denial from the NYMC/LDSS if the request to transfer to a MLTCP is denied. If the non-dual member provides evidence that he/she is in need of one or more of the services not covered by the MMCP, the LDSS or NYMC will refer the member to a MLTCP of their choice for a clinical assessment to determine if the MMCP member meets the criteria for Managed Long Term Care enrollment prior to actual enrollment into a MLTCP. If the member provides evidence that he/she has become eligible for Medicare and is now in receipt of Medicare, the LDSS or NYMC will refer the member to a MLTCP of their choice for a clinical assessment to determine if the member meets the criteria for MLTCP enrollment prior to actual enrollment into a MLTCP; or in non-mandatory districts advise of FFS options.

The MLTCP is permitted to find that the member does not meet MLTCP eligibility criteria and may notify the member of these findings. If the member is denied enrollment based on eligibility criteria and the member wishes to pursue enrollment, the MLTCP must transmit the application to the NYMC for required processing; or LDSS in non-mandatory districts.

To enroll into a MLTCP a member must meet the following eligibility criteria:

  • Age requirement based on MLTCP type Resident of MLTCP´s service area Medicaid eligible
  • Clinically eligible for MLTC based on assessment
  • Can be maintained in community without jeopardy to health and safety
  • Requires or is expected to require more than 120 days of community based long term care services (personal care; consumer directed personal care; adult day health care; home health care services; private duty nursing).

This policy does not affect a non-dual recipient´s right to initially choose a MLTCP instead of a MMCP if the recipient qualifies for MLTCP enrollment. However, once the recipient has elected to enroll into a MMCP, the above policy must apply. All plans are precluded from marketing to individuals who are already enrolled in a managed care plan and should focus on the enrollment of new members into MLTCPs.

The Transfer Request will be incorporated on the Exclusion/Exemption form which is currently used by the NYMC. This form requires a practitioner´s sign off in order for the member to move forward with the transfer, assuming all eligibility criteria for enrollment into MLTC are met. This form must be submitted as evidence that the member is in need of one or more of the services that cannot be provided by a MMCP. Additional documentation supporting the member´s need for services may be submitted, but the completed Transfer Request is required.