Dear Nursing Home Administrator Letter: Provided in advance of each Batch Process specifying nursing home responsibilities

  • Letter is also available in Portable Document Format (PDF)

July 23, 2021

Subject: Update - Nursing Home Benefit Limitation in Managed Long Term Care Partial Capitation Plans

Dear Nursing Home Administrator:

The purpose of this letter is to notify nursing homes of the intention of the Department of Health to conduct another "Batch Process" disenrollment to continue implementation of the change in coverage of the long term nursing home care benefit in the Medicaid Managed Long Term Care Partial Capitation plan (MLTCP plan). This "Batch Process" disenrollment will be effective October 1, 2021.

To implement this upcoming batch disenrollment, and as further described in the "Implementation and Information Required from Nursing Homes" section of this letter, the Department of Health (the Department) is requesting nursing homes transmit to the Department a list of all residents who are:

  • designated as long-term nursing home stay (LTNHS),
  • are enrolled in an MLTCP Plan,
  • and have an active discharge plan to transition to the community.

Note: The attached template must be completed and submitted no later than Friday August 6, 2021.

Reminder: Change in Long Term Nursing Home Benefit and Nursing Home Requirements

Under the December 2019 amendment to Medicaid Redesign Team (MRT) 1115 Demonstration Waiver, the nursing home MLTCP plan benefit is limited to three months of long-term nursing home care for individuals who are designated LTNHS (previously long term stay or permanently placed). The three-month benefit period begins on the first day of the month following the month of the effective date of the LTNHS designation documented by the nursing home, in conjunction with authorization by the MLTCP plan, on the LDSS-3559, "Residential Health Care Facility Report of Medicaid Recipient Admission/Discharge/ Readmission/Change in Status," form or an approved local equivalent. Note that the change in the long-term nursing home care benefit has no impact on rehabilitative, short term or temporary nursing home residents.

For new admissions and changes in status that occur, nursing homes are required to provide a copy of the LDSS-3559 to the resident, and any other individual representing the patient in their care with the nursing home. The LDSS-3559 is also required to be sent by the nursing home to the resident’s local department of social services (LDSS).

All MLTC plan enrollees are notified of the Nursing Home Benefit Limit (NHBL), either through the Benefit Announcement Letter from New York Medicaid Choice (NYMC) sent in January 2020 making them aware of the benefit change or, for more current enrollees, through a NHBL insert included with their enrollment confirmation notice received from NYMC.

Changes in Enrollment into MLTCP

As indicated in prior correspondence, individuals who are designated LTNHS have been excluded from enrollment into an MLTCP plan.

The change in the nursing home benefit does not apply to any other Managed Long Term Care products including Fully Integrated Duals Advantage - Intellectual/Developmental Disabilities (FIDA-IDD), Program of All-Inclusive Care for the Elderly (PACE), or Medicaid Advantage Plus (MAP). It also does not apply to Medicaid Managed Care Plans (Mainstream).

Implementation and Information Required from Nursing Homes

To accomplish disenrollment of affected plan members, the Department of Health, has initiated "Batch Process" disenrollments of MLTCP enrollees who were designated as LTNHS, had been in a LTNHS for more than three months (LTNHS 3+), and had been determined by the local social services district to be financially eligible for nursing home Medicaid coverage. "Batch Process" disenrollments occurred in August 2020, November 2020 and April 2021. Individuals who were included in the process have been converted to Medicaid FFS for on-going coverage of their long term nursing home care.

The October 2021 "Batch Process" will disenroll the members who meet the above criteria and were not included in the prior batch processes. It will be initiated and executed by the Department, and disenrolled members will be converted to Medicaid FFS for on-going coverage of their long term nursing home care, effective October 1, 2021. The process will establish the required entries in the Principal Provider Subsystem in the Welfare Management System (WMS) to initiate Medicaid FFS coverage for these individuals and direct payment to the nursing home. The individual will subsequently appear on the nursing home’s monthly roster.

MLTCP members who have been identified and verified as LTNHS 3+ members will receive the attached notice at least 10 days prior to disenrollment. Please note that the letter provides the member the opportunity to request an assessment to determine whether their needs can be met safely in the community. NYMC will work with the member and the plan to arrange for a requested assessment. Members who request an assessment before their disenrollment date will not be disenrolled from their MLTCP until they are notified by the plan of its decision.

The disenrollment notice will inform the individual that because financial eligibility for Medicaid coverage of nursing home care has been determined, after the disenrollment effective date, the individual’s nursing home care will be paid for through Medicaid FFS. If the individual has been paying income monthly toward the cost of nursing home care, the individual is to pay the monthly income directly to the nursing home. This notice also provides information about fair hearing rights. The involuntary disenrollment notice will be mailed by NYMC to enrollees identified by the Department.

MLTCPs will also be sending members the attached Notice of Intention to Disenroll from MLTC Medicaid Plan. This notice will go out to all members who have been identified and verified as LTNHS 3+ members. MLTCPs will mail the notice to all addresses that are authorized to receive notices for each member, including the identified member and their authorized representative if they have one.

The Department is now working closely with MLTCP plans to identify current MLTCP plan enrollees, as defined above, who are designated as LTNHS, have met or exceeded the three- month benefit period, and were not disenrolled in the prior batch processes. To ensure that members who may be in the process of transitioning to the community are not disenrolled from their MLTCP plan, please use the attached template to provide to the Department a list of your nursing home residents who meet the following criteria:

  • have been designated LTNHS,
  • are enrolled in an MLTCP Plan, and
  • who have an active discharge plan* to transition to the community.

The template includes the name of your nursing home, a contact person at your nursing home (name, telephone and e-mail), the transitioning resident’s name, Client Identification Number (CIN), date of LTNHS designation and the name of his or her MLTCP plan. Please transmit the completed template (in excel format) through the Health Commerce System (HCS) (instructions included) using the MLTC Nursing Home shared mailbox no later than Friday August 6, 2021.

  • *An active discharge plan means a plan that is being currently implemented. In other words, the resident’s care plan has current goals to make specific arrangements for discharge and/or staff are taking active steps to accomplish discharge. An active discharge plan includes situations where:
    • The resident is currently being assessed for transition by the Local Contact Agency; or
    • The resident has a Transition Plan in place, which has all the required elements and has been incorporated into the resident’s Discharge Plan; or
    • The resident has an expected discharge date of three (3) months or less, has a discharge plan in place with all the required elements, and the discharge plan could not be improved upon with a referral to the Local Contact Agency. In New York, the Local Contact Agency is Money Follows the Person/Open Doors and they can be reached at 844-545-7108.

      See "Guidance and Resources for Long Term Care Facilities: Using the Minimum Data Set to Facilitate Opportunities to Live in the Most Integrated Setting," U.S.

Department of Health and Human Services, Office of Civil Rights, May 20, 2016).

Note: If you do not have any members who fit the above criteria of an active discharge plan, please notify the department via DOH.sm.MLTCNH@health.ny.gov that you have reviewed and do not have any members that meet the criteria.

Prospective Disenrollments

The Department will issue additional guidance prior to implementing the disenrollment of any other designated LTNHS 3+ MLTC members.

Nursing Home Residents Returning to the Community

Nursing homes are reminded of the obligation to ensure that all residents who express a desire to return to the community are provided the opportunity and assistance to allow the resident to live in the most integrated and least restrictive setting possible. For additional information see Dear Administrator Letter 16:10, dated February 16, 2017, Dear Administrator Letter 18-05, dated September 4, 2018, and Dear Administrator Letter 19-16, dated October 11, 2019. Open Doors can also be reached at 844-545-7108.

Should you have any questions about this letter, please email the Department at DOH.sm.MLTCNH@health.ny.gov.

Sincerely,

Susan Montgomery, Director
Division of Long Term Care
Office of Health Insurance Programs

cc: Lisa Sbrana, NYSDOH
      Mike Ogborn, NYSDOH
      Kevin Wright, NYSDOH
      Ann Foster, NYSDOH
      Jonathan Bick, NYSDOH