Medicaid Benefits and Managed Long-Term Care

There are many different programs through which New York State pays for individual’s long-term care costs in both community and residential settings.  Beginning in April 2013 in Nassau and Suffolk counties, individuals who were eligible for both Medicare and Medicaid (dual eligibles), age 21 and over, who were in need of home care services for 120 days or more requiring a nursing home level of care were required to enroll in a managed Long Term Care Plan (“MLTC”).  The purpose of the MLTC is to provide case management and coordination of benefits.  Dual eligibles that were already receiving home care through the traditional Medicaid program were required to choose an MLTC and transition into their program.

The traditional Medicaid home care program was fee-for-service.  Home care agencies were paid based on the services provided.  MLTC payments are capitated – meaning that the managed Medicaid plan provider receives a fixed monthly amount per plan member – regardless of the amount of services actually provided.  The major concern surrounding the change to MLTC was that, with respect to home care services, no managed care provider would want to take on a split-shift case (two home health care aides each working a 12 hour shift) or even a 24/7 home care case because the reimbursement would be inadequate.  Indeed, there have been cases where hours have been cut.

The transition to MLTC has also brought about some positive changes to the home care program.  Instead of the consumer receiving just basic home care services, the managed care provider’s case managers are also assessing individuals for physical therapy, occupational therapy, social day care, podiatry, dentistry, optometry, audiology and even home modifications in an effort to provide a comprehensive plan of care.

Effective June 1, 2014, in New York City, Nassau, Suffolk and Westchester counties all eligible beneficiaries age 21 and over, in need of long term placement in a nursing facility, as defined by §1919(a)(1)(C) or 42 U.S.C. 1396r, will be required to join a Medicaid Managed Care Plan or a Managed Long Term Care Plan.  All individuals placed in a Medicaid certified skilled nursing facility prior to June 1, 2014, will remain in fee-for-service Medicaid.  They will not be required to enroll in Managed Care. However, as of December 1, 2014, any consumer who falls into this category will be allowed to enroll on a voluntary basis.  Individuals already placed in a skilled nursing facility will not be required to change nursing homes and will be covered as an out of network consumer if their current MLTC does not contract with the skilled nursing facility.

The application process for Medicaid benefits will basically remain the same.  The local department of social services under fee-for-service Medicaid performs eligibility determinations and this responsibility will remain in place with the transition to Medicaid managed care.  Uncompensated transfers during the look-back period will still be subject to a transfer penalty.  However, Net Available Monthly Income (NAMI), currently paid to the skilled nursing facility, will now be paid to the MLTC.

One major cause for concern is that not all MLTCs will contract all skilled nursing facilities.  Therefore, effective June 1, 2014, if an individual who is enrolled in a particular MLTC in the community suddenly requires care in a skilled nursing facility, the facility they choose may not have a contract with their MLTC.  In that case, the individual would either have to choose a different facility or disenroll from their current MLTC and enroll in an MLTC that contracts with that particular skilled nursing facility.

On a positive note, someone from the MLTC is required to visit with the consumer every six months to evaluate their current medical and social circumstances and their existing plan of care.  For consumers whose family members live out of state or are unfamiliar with the plethora of services available to their loved one, this will provide education and reassurance as it is an additional layer of patient advocacy.

Many advocacy groups would like to delay this expansion of Medicaid managed care to skilled nursing facilities.  There is concern that there are many systems yet to be put into place to deal with such a massive change.  Many of these advocacy groups feel that without adequate preparation, the rights of New York’s most vulnerable population may be violated; including those rights afforded them under the American’s with Disabilities Act.

Note: Melissa Negrin-Wiener is an elder law attorney and partner at Cona Elder Law based in Melville.  She manages the Government Benefits Department, while concentrating her practice in the areas of Medicaid eligibility planning, asset protection planning, disability matters, guardianships and estate planning.  She supervises the preparation of Medicaid Applications for nursing home care, home health care and community benefits.  She is a State Certified Guardian ad Litem, Court Evaluator, and Counsel to Guardians and incapacitated persons and is accredited by the Department of Veterans Affairs for the preparation, presentation and prosecution of claims for Veterans benefits.