People who are dual-eligible (meaning they have both Medicare and Medicaid), age 21 and older, and are in need of home care for more than 120 days are required to enroll in a Managed Long-Term Care (MLTC) plan. These plans are responsible for providing home care and other long-term care services (such as adult day care).
Different Types of Managed Long Term Care Plans
Partial MLTC Plans
PACE (Programs of All-Inclusive Care for the Elderly)
MAP (Medicaid Advantage Plus)
FIDA (Fully Integrated Dual Advantage)
Enrolling in a Managed Long-Term Care Plan
Making Changes in Managed Long-Term Care
Directory of Managed Long-Term Care Plans
Medicare and Medicaid recipients are entitled to an extensive list of coverage benefits. There are generally two ways in which beneficiaries may receive these benefits – “straight/non-managed” and “managed”. If someone has “straight/non-managed” Medicare and/or Medicaid, then the government administers these benefits directly – contracting with providers and paying for services. When a recipient enrolls in a “managed” plan, the plan receives a monthly premium from Medicare and/or Medicaid and is in turn responsible for supplying the member’s benefits.
There are four different types of Managed Long-Term Care plans: Partial MLTC, PACE (Programs of All-Inclusive Care for the Elderly), MAP (Medicaid Advantage Plus), and FIDA (Fully Integrated Dual Advantage). These four plan types can be broken down into two distinct groups – “partially managed” and “fully managed”. Partial MLTC plans only “manage” a portion of their members’ Medicaid benefits. They do not “manage” their members’ Medicare benefits at all. PACE, MAP, and FIDA “manage” all member benefits for both Medicare and Medicaid.
The following are descriptions of each plan type:
When someone enrolls in a Partial MLTC plan, the plan becomes responsible for administering a portion of the member’s Medicaid benefits, while the rest of their benefits remain “straight/non-managed” Medicaid. Partial MLTC plans do not affect a member’s Medicare at all. If someone has “straight/non-managed” [Original] Medicare, it will remain that way when they enroll in a Partial MLTC plan.
Partial MLTC plans manage the following Medicaid benefits:
- Home Care
- Adult Day Care
- Medical Equipment
- Ambulette transportation to doctor offices and clinics
- Outpatient physical, occupational, and speech therapy
- Audiology – including hearing aids and batteries
- Optometry – including eyeglasses
- Personal Emergency Response System (PERS)
- Nursing home care (where member is entitled to coverage)
The following Medicaid benefits remain straight/non-managed Medicaid:
- All doctors other than the four mentioned above
- All hospital care – inpatient, outpatient, and emergency room
- Outpatient clinics
- Lab tests
- Radiology tests
- Prescription drugs
- Mental health care
- Assisted living
It is important to note that, as always, Medicare will remain the primary health insurance for those that enroll in Partial MLTC plans. Medicaid will serve as a supplement to help cover gaps in Medicare coverage.
Enrolling in a Partial MLTC plan allows an individual to access long-term care services without affecting their coverage with respect to most other medical care. Their primary care physician (and most types of specialists) need not be in network with their MLTC plan, they can go to any hospital that accepts their Medicare, and they can get radiology and lab tests from any provider that accepts their Medicare.
Individuals must be age 18 or older to enroll in a Partial MLTC plan.
PACE plans “manage” all member benefits for both Medicare and Medicaid. As a result, members can usually only receive services from in-network providers. Plans have their own “adult day centers” where members see their primary care doctor and receive other services. Members can go to the center to participate in social activities with other plan members.
It is noteworthy that only two PACE plans exist in New York City.
Individuals must be age 55 or older to enroll in a PACE plan. Hence the “care for the elderly” in the name.
MAP plans “manage” all member benefits for both Medicare and Medicaid. As a result, members can usually only receive services from in-network providers.
Individuals must be age 18 or older to enroll in a MAP plan.
FIDA is the new kid on the block in Managed Long-Term Care. Similar to PACE and MAP plans, FIDA plans “manage” all member benefits for both Medicare and Medicaid. As a result, members can usually only receive services from in-network providers. However, FIDA plans are required to allow new members access to all current providers (even those out-of-network) for at least 90 days after a member joins the plan. That being said, that does not guarantee that providers will be willing to provide services under that arrangement.
One notable benefit of FIDA is that members are not subject to ANY premiums, deductibles, or co-pays. This includes prescription drugs. This also includes the Medicare Part B premium. Even those who don’t qualify to be in the Medicare Savings Program do not have to pay the Part B premium.
Another potential benefit of FIDA is coordination of care. Each member has an assigned care manager who is supposed to work with an interdisciplinary team. The team may include: the member or a designee, the member’s primary care physician, a behavioral health professional, the member’s home care aide, and more people where appropriate. The idea of the team being to help manage all of the member’s providers and services.
In theory, this could be helpful for many seniors, particularly those without loved ones willing to assist with care coordination. It remains to be seen how this will actually translate in practice; if companies will actually take an active role in coordinating their members’ care, or if they will choose to simply react to requests for assistance when members call – and many probably never will.
Individuals must be age 18 or older to enroll in a FIDA plan.
Those wishing to enroll in a MLTC plan must go through a two-stage process. First, they must undergo an nurse’s assessment from the Conflict-Free Evaluation and Enrollment Center (CFEEC). The CFEEC is administered by Maximus, NY State’s vendor, also known as NY Medicaid Choice. The purpose of the evaluation is to verify that the person seeking enrollment in fact requires long-term care.
Once Maximus approves a patient to enroll in MLTC, the patient will be given the opportunity to select a MLTC of their choice. Then, that MLTC will send another nurse so the MLTC can make their own evaluation. After the plan completes their assessment the patient can be enrolled into MLTC.
Enrollments are done on a monthly basis on the first of the month. Ostensibly, if all assessments and paperwork are completed by the 20th of a given month, a patient can be enrolled for the coming month. For logisitical reasons, this is not always the case in reality. If someone is hoping to enroll in MLTC for the coming month, having their assessments completed earlier in the month can enhance their chances of enrollment.
You may choose to change your MLTC plan at any time. Changes are made on a monthly basis and are effective on the first of the month. The process of making a change is as follows:
A consumer may contact any plan and request to switch to that plan. The enrolling MLTC plan will then send a nurse to evaluate the potential member. During the evaluation, the evaluating nurse will call NY Medicaid Choice together with the enrolling member to receive approval for the switch. After the evaluation, the enrolling plan will submit necessary enrollment paperwork to NY Medicaid Choice, who will approve and complete the enrollment. If someone needs assistance with selecting a plan, they can call NY Medicaid Choice directly at 888-401-6582. TIP: If a consumer is happy with the licensed home care services agency (LHCSA) that is sending the home health aide or personal care aide, but would like to switch MLTC plans, they can call the LHCSA directly and ask for their assistance in switching to a plan with whom they are contracted. This will help ensure that they remain the provider for the home attendant once the change is made.
Similar to new enrollments, ostensibly, a change can be effective for the coming month if everything is completed by the 20th of the previous month. Here too, this is not always the case in reality. If someone is hoping to change plans for the coming month, having their assessment completed earlier in the month can enhance their chances of the change going through.
It is important to be aware that just because a plan sends a nurse to evaluate you to switch to them, that does not obligate you to go through with the change. If you are not satisfied with the services being offered by the new plan, you may choose to decline the change.
We provide free assistance with enrolling in Managed Long-Term Care. If you would like assistance for yourself, a loved one, or a client, please give us a call. Call Us Now! 718-838-3838