DOH Modifies Proposal for Managed Care of Nursing Home Residents

Under DOH's proposal that would begin Jan. 1, 2014, persons who are permanently placed in a nursing home prior to the phase-in dates outlined below would remain in the Fee-For-Service (FFS) system for the duration of their nursing home stay (unless they voluntarily enroll in FIDA or are passively enrolled in FIDA and do not opt out). Nursing home residents that are not already permanently placed in nursing homes as of the effective dates below will be enrolled as follows:

1. If in FFS, they will remain in FFS until eligibility for permanent placement is determined and then they will enroll in a plan Managed Long Term Care (MLTC) for duals/Mainstream Medicaid Managed Care (MMMC for non-duals).
    
2. If already enrolled in a plan, they will remain in that plan and the plan will cover the entire nursing home stay.
    
3. If they are new to Medicaid, and they are not otherwise exempted or excluded, they will be mandatorily enrolled in a managed care plan upon being determined to be Medicaid eligible. The plan will cover the nursing home stay from the date of enrollment in the plan (MLTCP for duals/MMMC for non-duals).  

For adults (age 21 and older), the effective date would be Jan. 1, 2014 for New York City, Westchester, Nassau and Suffolk counties. The rest of the state would begin implementation on April 1, 2014. This applies to both specialty and non-specialty nursing home residents. For pediatric residents, this policy would take effect statewide on April 1, 2015.

Most non-duals residing in nursing homes on a non-permanent basis (e.g., for rehabilitation) are already in managed care and their plan is covering the short term nursing home benefit. If those persons are deemed permanent residents of a nursing home, under this proposal they would not be disenrolled from managed care, and instead the managed care plan will be required to cover the permanent nursing home stay. Dual-eligibles receiving long term care in the community and already enrolled in a plan would continue in the plan if they are placed in a nursing home on a temporary or permanent basis.

FIDA enrollment will be optional (voluntary) for all (FFS and managed care) dual eligible nursing home residents on Oct. 1, 2014 in the FIDA region (Westchester, Long Island and NYC). FIDA passive enrollment (with opt out capability) will begin for all nursing home residents on Jan. 1, 2015 for NYC, Westchester and Long Island. Persons that opt out of FIDA will either remain in FFS or the plan in which they were already enrolled.

Several questions and issues were raised during the work group meeting and in breakout sessions on reimbursement; network/contracting; eligibility/enrollment; and access/quality.

LeadingAge New York's Nursing Home Managed Care Work Group will be meeting again in the near future to discuss these issues and make recommendations on future strategy.

Contact: Dan Heim, dheim@leadingageny.org, 518-867-8866