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New DOH Policies on Medicaid Managed Care

Last week the Department of Health (DOH) released two new important managed care policies:

1.)    MLTC Policy 15.02: Transition of Medicaid Managed Care (MMC) Enrollees to Managed Long
Term Care (MLTC)

This policy ensures that MMC enrollees receiving Community Based Long Term Care (CBLTC) may avoid a lapse in coverage by directly enrolling them into MLTC plans, unless they are exempt or excluded.

MMC enrollees who have or are expected to have 120 days or more of CBLTC services, as verified by the MMC plan, will not have to be assessed by the Conflict Free Evaluation and Enrollment Center (CFEEC) in order to enroll in an MLTC plan. The MMC enrollees will be provided educational materials by New York Medicaid Choice (NYMC) on MLTC plan options to ensure freedom of choice in deciding which MLTC plan to join. NYMC will send MMC enrollees a letter two to four months prior to their 65th birthday outlining the process.

If a MMC enrollee does not select a MLTC plan they will be autoassigned into an MLTC by the State. For MMC enrollees whose plans already have an affiliated MLTC they will be transferred into that MLTC by the State. It is important to note that MLTC enrollees will continue to have the option to transfer to another MLTC at any time.

2.)    MLTC Policy 15.03:  End of Exhaustion Requirement for MLTC Partial Capitation Plan Enrollees 

MLTC plan enrollees may now request a State fair hearing from the NYS Office of Temporary and Disability Assistance (“OTDA”) without first exhaisting the plan's internal appeals process.  This new policy is effective with MLTC plan decisions made on or after July 1, 2015 that deny, reduce or discontinue services. In other words MLTC enrollees are no longer required to exhaust their plan’s internal appeals processes before obtaining a State fair hearing .

This new policy also impacts aid-continuing in several ways, including:

  • Aid-continuing is no longer available if the enrollee asks only for an internal appeal of a plan’s proposed reduction or discontinuance of services and does not also request a State fair hearing;
  • To get aid-continuing, enrollees must request a State fair hearing within 10 days of the MLTC notice;
  • Enrollees do not need to specifically request aid-continuing to obtain it, but they may tell OTDA that they specifically decline it; and
  • The 60 day deadline to request a State fair hearing begins running as of the date of the MLTC notice.

This new policy is for MLTC enrollees. Enrollees in MAP or PACE must continue to exhaust the internal appeal process before requesting a State fair hearing.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871 or Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827.