Managed Long Term Care (MLTC) Policy 25.04: Minimum Needs Requirement Update to the Eligibility Requirements for Managed Long Term Care Enrollment
- MLTC Policy 25.04 is also available in Portable Document Format
Date of Issuance and Revision: June 30, 2025
Effective Date: September 1, 2025
Purpose: This policy is to provide guidance and instructions regarding changes to the Managed Long Term Care (MLTC) eligibility criteria in accordance with Public Health Law § 4403-f. Effective September 1, 2025, the New York State Department of Health (Department) will implement a change in the MLTC Program eligibility criteria for MLTC Partial Capitation (MLTCP) and Medicaid Advantage Plus (MAP) plans. The new program eligibility criteria are referred to as Minimum Needs Requirements and do not apply to enrollment in Programs of All- Inclusive Care for the Elderly (PACE) plans.
Scope : The Minimum Needs Requirements, as defined below, apply to MLTCP or MAP plan enrollment criteria beginning on and after September 1, 2025. Individuals enrolling into a MLTCP or MAP plan on or after September 1, 2025 must meet the Minimum Needs Requirements at initial and subsequent assessments in addition to the need for Community Based Long Term Services and Supports (CBLTSS) for more than 120 days. Individuals enrolled in any MLTC plan prior to September 1, 2025, will be granted Legacy Status, as defined below, and will not be subject to the new Minimum Needs Requirements at reassessment if they remain continuously enrolled in any MLTC plan. This policy does not change PACE enrollment eligibility criteria; however minimum needs criteria for Personal Care Services (PCS)/Consumer Directed Personal Assistance Services (CDPAS) applies to members initially seeking services after September 1, 2025.
Note : While PACE is not subject to the Minimum Needs Requirement for enrollment, individuals with PACE will be granted Plan Legacy and Service Legacy following the same process as other MLTC plans. This status will allow individuals, enrolled in PACE prior to the implementation, to transfer within MLTC lines of business.
A. Definitions
MLTC Plan Legacy Criteria (Legacy Criteria) – the eligibility criteria in effect before September 1, 2025, as outlined in Table B.
Legacy Status - a classification of eligibility criteria that applies to an individual who was enrolled in PCS, CDPAS, or MLTC prior to September 1, 2025. The Uniform Assessment System (UAS-NY) will include an indicator for legacy status that identifies individuals that will not be assessed or reassessed using the new Minimum Needs Requirements.
MLTC Plan Legacy (Plan Legacy) – a status for individuals enrolled in MLTC, including PACE, before September 1, 2025. Plan Legacy individuals will be reassessed using Legacy Criteria if they remain continuously enrolled in any MLTC plan.
Personal Care Services (PCS)/Consumer Directed Personal Assistance Services (CDPAS) Service Legacy (Service Legacy) – a status for individuals receiving or authorized for PCS or CDPAS before September 1, 2025. Service Legacy will be assessed and reassessed using PCS/CDPAS Legacy Criteria.
Minimum Needs Requirements (Minimum Needs) – Refer to Table A. The eligibility criteria for MLTCP and MAP, in accordance with Public Health Law § 4403-f, that requires an individual initially assessed on or after September 1, 2025, as needing CBLTSS for more than 120 days and the following:
- at least limited assistance with physical maneuvering with more than two activities of daily living (ADLs); or
- individuals with a Dementia or Alzheimer's diagnosis, assessed as needing at least supervision with more than one ADL
B. Changes to Eligibility Requirements:
Effective September 1, 2025, individuals enrolling into MLTCP or MAP must be in need of Community Based Long Term Services and Supports (CBLTSS) for more than 120 days and meet the Minimum Needs Requirements as follows:
- at least limited assistance with physical maneuvering with more than two activities of daily living (ADL); or
- individuals with a Dementia or Alzheimer's diagnosis, at least supervision with more than one ADL.
Individuals with Plan Legacy Status will continue to be assessed using the Legacy Criteria as long as they remain continuously enrolled in any MLTC Plan. Refer to Table B of this guidance for additional information about criteria for individuals with Plan Legacy Status.
i. Alzheimer's or Dementia Documentation Requirements
- Individuals with a Dementia or Alzheimer's diagnosis assessed under the Minimum Needs Requirements must provide documentation of the diagnosis at each assessment using the Alzheimer's Disease or Dementia Form (DOH-5821)..
- The Alzheimer's Disease or Dementia Form (DOH-5821) must be completed with the individual's name, date of birth, diagnosis(es), diagnosis ICD-10 code(s), practitioner name, and practitioner license number. The information in this form can be completed the licensed health care professionals listed on the form. However, the diagnosis must be made by a physician (M.D. or D.O.). The physician does not need to be a NYS Medicaid Provider.
- Note : Documentation for Alzheimer's Disease or Dementia is required at each assessment where the condition is present unless the individual with a Dementia or Alzheimer's diagnosis is assessed as needing assistance with physically maneuvering with more than two activities of daily living or as otherwise directed by the Department.
C. Maintenance of Legacy Status
MLTC Plans will be responsible for adding and removing Legacy Status to the individual's case in the UAS-NY.
ii. Granting Legacy Status
Certain individuals will be granted Legacy status as follows:
- Enrolled in an MLTC Plan: Individuals enrolled in any MLTC Plan, including PACE as of August 1, 2025. The Department will grant MLTC Plan and Service Legacy Status to these individuals in the UAS-NY.
- Assessed but not yet Enrolled in an MLTC Plan: Individuals that were assessed after August 31, 2024, but prior to September 1, 2025, and are enrolled in MLTC within one year of the date of their assessment, will be granted MLTC Plan and Service Legacy by their MLTC Plan. Date of assessment must be determined in the UAS-NY.
- Assessment scheduled and not yet Enrolled in an MLTC Plan: Individuals with an initial assessment scheduled before September 1, 2025, whose appointment is rescheduled through no fault of their own to after September 1, 2025, will be eligible under the pre-September 1, 2025 criteria. If the individual enrolls in MLTC within one year of the assessment, the MLTC Plan will grant Plan and Service Legacy. The New York Independent Assessor Program (NYIAP) will confirm this scenario applies in the Sign and Finalize notes in the UAS-NY. Note : The rescheduling must be done before the date of the initial scheduled appointment.
When an individual enrolls into an MLTC Plan after September 1, 2025, the MLTC Plan must ascertain when the assessment used to determine eligibility was completed. If the assessment was completed prior September 1, 2025 (or as described at C.i.3. above) the MLTC plan will add Plan Legacy and Service Legacy to the individuals' case file in UAS-NY.
Reminder: While PACE is not subject to the Minimum Needs Requirement for enrollment, individuals with PACE will be granted Plan Legacy and Service Legacy following the same process as other MLTC plans. This status allows individuals in PACE to transfer within MLTC lines of business.
iii. Removal of Plan Legacy Status
In order to retain Plan Legacy, the member must be continuously enrolled in the MLTC Program, including PACE. MLTC plans must educate members about the loss of Plan Legacy Status prior to disenrollment. MLTC plans, including PACE Plans, are responsible for maintaining the Plan Legacy Status indicators in the UAS-NY. Plan Legacy will only be removed by the MLTC plan when a member is disenrolled from the MLTC Program.
If the member is transferring to another MLTC plan with no break in enrollment, the Plan Legacy will remain on file. The MLTC plan must verify that the member is transferring to another plan.
Note : Service Legacy is not impacted by an MLTC disenrollment and should not be changed.
D. NYIAP Initial Assessments
NYIAP will conduct the initial assessment for individuals seeking PCS/CDPAS and/or enrollment into the MLTC program. During the scheduling process NYIAP will educate the individual on the Alzheimer's or Dementia Documentation Requirements.
Upon completion of the initial assessment, NYIAP will send an outcome notice to the member explaining next steps and fair hearing rights. This notice will indicate if the individual meets the criteria for enrollment into MLTCP and MAP and will include outcomes for PACE enrollment. Refer to Table A.
The notice also informs the individual if they were determined medically stable to receive PCS/CDPAS. Note: MLTC plans should not deny enrollment for an individual determined medically unstable, unless the MLTC plan is unable to provide any other CBLTSS the individual is eligible to receive.
Variance Requests : When using a Community Health Assessment (CHA) completed by NYIAP, inaccuracies could be identified that are either clinical, such as judgement of the individual's presentation at the time of separate appointments, or factual. For information on the CHA Variance process, please refer to MLTC Policy 22.01. Plan Legacy will be based on the date of finalization of the NYIAP assessment that was performed before the CHA Variance request. If a NYIAP Variance Process results in NYIAP conducting another initial assessment, the Legacy Criteria will be used if the original assessment date was prior to September 1, 2025. The Practitioner Order cannot be disputed as part of the Variance submitted by the District or Managed Care Plan.
E. MLTC Plan Reassessments
MLTC plans will conduct reassessments to determine continued MLTC eligibility and reauthorize services for all enrolled Members. The reassessment process continues to be initiated with a completed Physician's Order to the MLTC plan.
Prior to conducting the reassessment, including reassessments for a sudden change in condition (SCIC), the MLTC plan must review the UAS-NY to confirm the individual's Plan Legacy Status.
i. Individuals without Legacy Status
When an individual without Legacy Status is reassessed for MLTCP or MAP, the Minimum Needs Requirements must be used to determine their MLTC eligibility. For additional information Minimum Need Requirement refer to Table A.
Alzheimer's Disease or Dementia Documentation Requirements:
When an individual meets the Minimum Needs Requirement with a diagnosis of Dementia or Alzheimer's based on the lower threshold of at least supervision with more than one ADL, they must provide appropriate documentation of Alzheimer's or Dementia as outlined in the Alzheimer's or Dementia Documentation Requirements section. The MLTC plan must educate the individual on the Alzheimer's or Dementia Documentation Requirements, if needed. If the required documentation is not provided the lower threshold cannot be applied.A copy of this documentation shall be retained in the member's file. The MLTC plan must record the date of documentation of Alzheimer's or Dementia diagnosis in the individual's case notes and UAS-NY Section H: Disease Diagnoses.
Refer to section Alzheimer's or Dementia Documentation Requirements for additional information.
ii. Individuals with Legacy Status
When an individual with Plan Legacy Status is reassessed for MLTCP or MAP, the pre-September 1, 2025 criteria must be used to determine MLTC eligibility and/or used to reauthorize services for all enrolled Members. For additional information regarding pre-September 1, 2025 criteria (Legacy Criteria) refer to Table B.
Note : Documentation for Alzheimer's or Dementia is not required for a Plan Legacy individual.
Before the MLTC Plan completes a reassessment, the MLTC Plan will review the UAS-NY to confirm the Plan Legacy status of an individual and use the applicable criteria in determining eligibility.
F. UAS-NY System Implications
The UAS-NY 1.18 Release in October 2024 includes the new Minimum Needs Requirements. This Release included Plan and Service Legacy Status in the Assessment Outcomes and LTC Legacy Status fields. The UAS-NY will release the Legacy Node after September 1, 2025 that will allow viewing and editing of the Legacy Status information.
The UAS-NY will show information in the CHA Assessment Outcomes and LTC Legacy Status fields that indicates the Plan and Service Legacy Status of individuals. Authorized users will be able to edit Legacy by selecting this option in the UAS-NY.
The viewing and editing of Legacy Status mentioned above will not be visible until the one- time update after September 1, 2025. The MLTC plan is expected to continue to track and update Legacy going forward.
i. Legacy Fields in UAS-NY
Plan Legacy at the time of Implementation : When “No” is preselected in the MLTC Plan Legacy Status field, the individual does not have Plan Legacy status. The MLTC Plan Legacy Status field will be “Yes” when it was either added at implementation or afterward as described below.
Plan Legacy after Implementation: For individuals that were assessed one year prior to September 1, 2025, the MLTC plan must add MLTC Plan Legacy if the individual is enrolled within one year of the date of their assessment. When Plan Legacy is not already reflected, Plan Legacy will need to be added by selecting “Yes” for the MLTC Plan Legacy Status field and entering the MLTC Plan Legacy Status Start Date which should correlate to the enrollment date. The MLTC Plan Legacy Status End Date must be entered when the member is disenrolled from the MLTC plan.
Service Legacy at the time of Implementation : When “No” is preselected in the PCS/CDPAS Service Legacy Status field, the individual does not have Legacy Status. The PCS/CDPAS Service Legacy Status field will be “Yes” when it was either added at implementation or afterward as described below.
Service Legacy after Implementation: For individuals that were assessed prior to September 1, 2025, the MLTC Plan must add Service Legacy if the individual is enrolled within one year of the date of their assessment. When Service Legacy is not already reflected, Service Legacy will need to be added by selecting “Yes” for the PCS/CDPAS Service Legacy Status field and entering the PCS/CDPAS Service Legacy Status Start Date which should correlate to the enrollment date.
Legacy Status training in the UAS-NY will be available to all Long Term Care and Long Term Care Independent Assessor users prior to September 1, 2025. The training will go live in the weeks before September 1, 2025. This training will cover how to locate and understand the LTC Legacy Status node, Legacy Status in the Assessment Outcomes node, and provide descriptions of the fields within the UAS-NY. This training will remain recommended until early September 2025, when the training will become required. Required dates are staggered for LTC and LTC-IA user roles.
Specific training for those with Edit Access will also be available prior to September 1, 2025 for roles: LTC-02, 15, 45, and 50. This course covers the step-by-step procedure to update Legacy Status using the most common scenarios users will encounter.
G. Table A
MLTC Eligibility Criteria including Minimum Needs Requirements* | |||
---|---|---|---|
Population | MLTC – Partial | MAP | PACE |
Dual eligible 18 - 20 | Must be assessed to:
|
Must be assessed to:
|
Not eligible: Must be 55 or older |
Dual eligible 21 and older | Must be assessed to:
|
Must be assessed to:
|
Must be assessed to:
|
Non-dual eligible over 18 | Must be assessed to:
|
Not eligible: Must be dual | Must be assessed to:
|
*For individuals without other exclusion reasons.
H. Table B
MLTC Plan Legacy Criteria* | |||
---|---|---|---|
Population | MLTC - Partial | MAP | PACE |
Dual eligible 18 - 20 | Must be assessed to:
|
Must be assessed to:
|
Not eligible: Must be 55 or older |
Dual eligible 21 and older | Must be assessed to:
|
Must be assessed to:
|
Must be assessed to:
|
Non-dual eligible over 18 | Must be assessed to:
|
Not eligible: Must be dual | Must be assessed to:
|
*For individuals without other exclusion reasons
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