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Medicaid Reform

What it means for long term care in New York State

What is changing?

Over the next two years, everyone in New York State who are currently receiving long term care services at home, enrolled in programs that allow them to stay at home while going to a center for medical and social services daily, or receive services from home health aides for more than 120 days a year will have to enroll in a Managed Long Term Care (MLTC) plan.

Why?

Managed Long Term Care has been shown to be an extremely effective way to provide health care to those in need. It is also a very cost-effective delivery model. That’s important in New York State, which has the most expensive Medicaid system in the nation. Using a managed care model for patients who are enrolled in Medicaid is expected to be a major step towards helping them continue to live safely in their homes and communities while significantly reducing costs.

What is managed care? 

A health care organization or a health plan provides a package of pre-defined services for a set monthly fee. With managed care, all aspects of a person’s care are coordinated -- from appointments to home care visits to medical transportation to treatments by various specialists -- therefore avoiding duplication and delays and reducing costs.

Who will be affected by this change? 

Anyone 21 or older who is eligible for both Medicare and Medicaid (“dual eligible”) and who is determined to need home or community-based long term care services for more than 120 days. Medicaid Reform specifically targets recipients who have multiple chronic conditions and/or a serious medical illness.

Why will this be better for people who need these services? 

Currently these individuals may be getting help from several different agencies and paying a fee for each service. For example, one organization might provide home care, another might send a nurse, and yet another might offer a day care program. Meanwhile, none of these providers has an overall view of what treatment or treatments will provide the best results.

Once enrolled in a Managed Long Term Care (MLTC) plan, the individual will have one organization responsible for providing or arranging for all the needed services and putting together a plan of care based on each patient’s particular needs. That means the individual could get, for example, medical care, rehabilitation and recreational therapy, transportation, meals, home care, adult day health care, nursing home care if needed, and other services, depending on his or her need.

Who pays for these services? 

Medicaid and Medicare cover the costs of long term care for qualified enrollees. In the most common managed care arrangement the state pays the health care organization a fixed monthly fee to provide coordination and care services for every enrollee. This reimbursement method is called capitation.

When will these changes take place? 

The final plan has not yet been officially approved by the Center for Medicare and Medicaid Services (CMS), but mandatory enrollment has already started in Manhattan in July. Other boroughs and counties will transition to managed care on a rolling basis over the next two years (see schedule on the right).

How will people know when and if they have to enroll?

For recipients of community-based long-term care who are currently enrolled in Medicaid, enrollment will be phased in batches. This would be done by borough and by zip code. People will be given 60 days to choose a plan according to a set schedule, which is still being finalized and awaiting approval. Please refer to the sidebar on right of this page for the proposed schedule as of August 6, 2012.

On July 1, 2012, new Medicaid dual eligibles started receiving a letter giving them 30 days to voluntarily select a managed care provider. If no plan is selected, one will be chosen for them by the New York State Department of Health.

What if I am already enrolled in a managed care program?

Anyone who is already in a Managed Long Term Care (MLTC) plan and is happy with their services doesn’t need to do anything.

How will people know what their options are?

When the transition to managed care begins, the state Department of Health will be providing packets of information to help people understand what they need to do to enroll. Counselors will also be available by phone to answer questions about joining a plan.

For more information, visit the NYS DOH website by clicking here.

Medicaid Reform Schedule


The exact schedule is still awaiting final approval but enrollment begun in July and will be phased over the next two years. The actual timing will depend on the type of service an individual receives and the borough in which he or she lives.


After each effective date, any new Medicaid applicants in that borough wanting to receive community-based long term care services will have to enroll in a managed long term care plan.


July 1, 2012: New York County (Manhattan)

September, 2012: Bronx County

October, 2012: Kings County (Brooklyn)

December, 2012: Queens and Richmond (Staten Island) counties

January 2013: Nassau, Suffolk and Westchester counties

 

CENTERLIGHT