MLTC Partial Plan Additional Rate Codes Letter

August 11, 2014

All Partially Capitated Managed Long Term Care Plans

Rate codes 3479 and 3480 have now been added to profiles for MLTC Plans on any counties designated mandatory as of June 2014. In order to minimize rebilling efforts by MLTC plans, the New York State Department of Health (NYSDOH) will implement the rebilling procedure as described below.

These rate codes were added as the result of a collaborative effort between the Plans and the NYSDOH 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 are mandated to join a MLTC Plan. 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, detetmination 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 has been and continues to be phased in geographically in accordance with the CMS approved waiver phase-in plan. Approved counties and effective dates where Plans may begin billing rate codes 3479 and 3480 are listed in the Rebilling Process below. The NYSDOH will continue to notify Plans through the current rate development process as premiums are developed throughout the phase-in.

Rebilling Process

Previously paid capitation claims for mandatory enrollment for periods prior to the date of this letter that will be submitted for adjustments, must be submitted no later than September 30, 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. This includes the following counties approved for mandatory transition effective as of the date shown:

July 1, 2012 - NYC personal care cases
November 1, 2012 - NYC consumer directed cases
January 1, 2013 - NYC ADHC cases
January 1, 2013 - Nassau, Suffolk, Westchester personal care, consumer directed & ADHC cases
March 1, 2013 - NYC, Nassau, Suffolk, Westchester Home Health over 120 days, PDN cases
April 1, 2013 - NYC, Nassau, Suffolk, Westchester LTHHCP cases
September 1, 2013 - Orange, Rockland
December 1, 2013 - Albany, Erie, Onondaga, Monroe
April 1, 2014 - Columbia, Putnam, Sullivan, Ulster
May 1, 2014 - Rensselaer, Cayuga, Herkimer, Oneida
June 1, 2014 - Greene, Schenectady, Washington, Saratoga

With the exception ofNYC only, capitation claims should be billed with approved risk adjusted premium rate amounts. As mandatory premium rate amounts become available and all necessary approvals are obtained, retro-active rate adjustments will be processed by NYSDOH at a future point in time when revised premiums are loaded to the eMedNY system.

For NYC, capitation claims should continue to be billed with approved mandatory transition rate amounts and retro-active rate adjustments will be processed automatically by NYSDOH at a future point in time when revised premiums are loaded to the eMedNY system.

The benefit of this process is that Plans may begin rebilling capitation claims immediately, and future premium adjustments will be processed automatically.

The eMedNY website at: https://www.emedny.org/info/TimelyBillinglnformation 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