The Medicaid Committee and Fair Hearing and Litigation Committee of the Elder Law Section of the NYS Bar are collecting information about your experiences with MLTC in all counties outside of New York City and its boroughs (HRA). Please take a few moments to read this letter and complete the survey at the end.
In addition to NYC, MLTC enrollment is currently mandatory in Westchester, Nassau and Suffolk Counties. In the mandatory enrollment counties, as in NYC, one must first apply for Medicaid, and once approved, enroll in an MLTC plan (or, alternatively, a Medicaid Advantage Plus plan or PACE plan).* Enrollment in these plans can only begin on the 1st of any month. In order to be enrolled in a plan by the 1st of any month, you must actually enroll - sign the enrollment form - by the 15th of the month prior, to allow necessary computer coding to be entered by the 19th.
The federal approval of the MLTC program requires that the plan "complete the initial assessment in the individual's home of all individuals referred to or requesting enrollment in an MLTC plan within 30 days of that referral or initial contact.** We assume that this 30-day requirement is for people whose Medicaid was already accepted.
There is potential for delays at many points of the application process:
1. If Medicaid is accepted after the 15th of the month, there is not enough time to find and enroll in a plan for enrollment to be effective on the 1st of the next month. So enrollment is delayed another full month. During that time your client must private pay for services, or obtain temporary CHHA services "MLTC pending."
2. Even when Medicaid is accepted earlier in the month, there is time pressure to select a plan and enroll by the 15th for services to begin by the 1st of the next month.
3. You can choose a plan before Medicaid is accepted - ask them to assess your client and give you a plan of care while the application is pending, so you are ready to enroll as soon as Medicaid is accepted. (See State DOH Q&A issued Aug. 21, 2012 - Question 39 and 42.) Because the plans are deluged with not only new applicants but with the need to assess thousands of former CASA/DSS recipients who are transitioning from the former system, they are backlogged in doing the home visits needed to assess and enroll new members. They may refuse to come and assess someone who does not already have a Medicaid acceptance.
4. If client enrolls in a plan, and the plan of care was not already set up before the effective date of enrollment, there may be a delay until the nurse comes to assess the client and then until services actually start.
5. One way of expediting the process might be to apply for Medicaid in the first place by having a preferred plan submit the Medicaid application, instead of you filing it directly with DSS. While this may be happening in NYC, we are not clear whether this will be available outside of NYC. Some of the plans help prepare and submit Medicaid applications, along with pooled trusts, as a marketing tool to draw members. Of course you want to prepare the application and ensure all documentation is included. The plans may not start service, though, until the 1st day of the month after Medicaid is approved - and might be delayed another month as explained above. Member may switch to a different plan.
We need your assistance. In particular, we are tracking raw data on:
The 'time lag,' if any, between your client's notice of decision of Medicaid (acceptance) and start of services under MLTC, particularly for new applications which seek home care and adult day care services.
NOTICES - Plans must give notice of the initial authorization so that a member may appeal inadequate hours or denial of certain services, e.g. plan may substitute other services such as PERS, adult day care, or home-delivered meals for desired hours of home care. Note that the initial appeal must be an
internal appeal within the plan, followed by the right to a fair hearing if the internal appeal decision is adverse. See article on appeal and grievance rights. Some plans maintain that if client signs the initial plan of care, this means client agrees to the plan of care
and waives appeal rights. This not true.
Please answer the questions on the following survey. The more information provided about a specific experience, the better the database will be. The data will be presented to the Section and its members for further consideration, review and, if necessary, litigation. MLTC Survey
Thank you for your time,
Valerie Bogart, Medicaid Committee
Beth Polner Abrahams and Melinda Bellus, Fair Hearing and Litigation Committee
* Contact lists for plans in all counties are on the New York Medicaid Choice website - this is the state contracted enrollment broker. http://www.nymedicaidchoice.com/program-materials - See Long Term Care plans for your county. Also see article on Tools for Choosing an MLTC plan at
** CMS Special Terms & Conditions Sept. 2012, p. 18, http://www.health.ny.gov/health_care/medicaid/redesign/docs/partnership_amendment_stc.pdf