MLTC Policy 14.07

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 14.07: Adult Day Health Care and Managed Long Term Care: Revisions to 10 NYCRR Part 425

Date of Issuance: October 16, 2014

Regulations were recently adopted enabling Adult Day Health Care (ADHC) providers to contract with Managed Long Term Care (MLTC) plans utilizing an optional unbundled rate structure.

ADHC providers will be permitted to offer an unbundled services/payment option, providing opportunity for individuals who require less than the full range of ADHC services to receive the services specific to their individualized care plan; thus enabling the ADHC provider to bill the MLTC plan accordingly.

The adopted regulations are posted at: http://www.health.ny.gov/regulations/recently_adopted/docs/2014-09-10_adult_day_health_care_mltc.pdf.

In order to utilize this alternative, the ADHC must properly notify the Department of election of the unbundled services/payment option. MLTC plans who wish to pursue this option will need to amend ADHC contracts in accordance with the Department's Provider Contract Guidelines.

The focus of this policy directive is to clarify the impact of the regulatory change in relation to the criteria for enrollment in all MLTC products.

The definition of Community Based Long Term Care Services (CBLTCS) remains:

An Enrollee is expected to require at least one (1) of the following Community Based Long Term Care Services (CBLTCS) covered by the MLTC plan for more than 120 days from the effective date of enrollment:

  1. nursing services in the home;
  2. therapies in the home;
  3. home health aide services;
  4. personal care services in the home;
  5. adult day health care;
  6. private duty nursing; or
  7. Consumer Directed Personal Assistance Services

Please note that Enrollee participation in an ADHC and authorized for a limited service does not constitute need for CBLTCS and eligibility for plan enrollment. Enrollees authorized for an ADHC unbundled service option must also be in receipt of another qualifying CBLTC service to be considered appropriate for MLTC.