MLTC Policy 14.04

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 14.04: MLTCP Potential Enrollee Assessments

Date of Issuance: May 22, 2014

This policy guidance is intended to clarify the current required potential enrollee assessment process conducted by a Managed Long Term Care Plan (MLTCP) prior to a consumer´s actual enrollment.

A Potential Enrollee means a Medicaid recipient who is eligible to enroll in a managed long term care plan, but is not yet an Enrollee of a Managed Long Term Care Plan.

An initial assessment may be conducted at an institutional residence, such as a residential health care facility (nursing home).

When a MLTCP receives a prospective enrollment referral from a nursing home on behalf of a Medicaid recipient, the MLTCP must assess the consumer in a timely manner, within 30 days of receiving the referral. The MLTCP should assess the consumer where the consumer is located at the time of the referral, i.e., the nursing home. The assessment conducted in the nursing home setting will include and consider: diagnoses; current Plan of Care; discharge plan; proposed community residence; tentative discharge date; and need for community based long term care services.

In addition to the assessment conducted in the nursing home, the MLTCP must also assess the potential enrollee´s proposed community residence which must be available for viewing prior to the date of discharge. A home visit by the MLTCP is required to determine the potential enrollee´s health and safety in the actual residence, identify any risk factors, and develop an effective and efficient Plan of Care. The potential enrollee does not need to be at the proposed residence during the home visit.

As the MLTCP is responsible for the consumer´s health and safety beginning on the enrollment date, the assessment process must be completed, the final definitive Plan of Care established, and MLTCP services must be in place for the consumer on day of discharge to the community setting.