DOH Issues MLTC-LHCSA Contract Limitation Guidance
The Department of Health (DOH) has issued guidance on the implementation of the state budget provision limiting the number of Licensed Home Care Services Agencies (LHCSAs) with which a Partially Capitated Managed Long Term Care (MLTC) plan may contract. The document, available here, outlines enrollee notification requirements, provides examples of calculating the maximum ratios, addresses special situations, and details the exceptions process.
The 2018-19 State Budget limits the number of LHCSAs with which Partially Capitated plans may contract effective Oct. 1, 2018. The limits are based on the number of members the plan has on July 1, 2018. Downstate plans may contract with one LHCSA for every 75 members, while the limit for plans serving upstate areas is one for every 45 members.
The LHCSA-to-member ratios tighten the following year. Effective Oct. 1, 2019, and based on their July 1, 2019 enrollment, downstate plans may contract with one LHCSA for every 100 members, while the limit for upstate plans will be one LHCSA for every 60 members. These limits will remain going forward but will be recalculated each year based on a plan’s July 1st enrollment. In most cases, plans that operate both upstate and downstate and contract with an agency that serves both regions would have that agency counted when both upstate and downstate limits are computed.
LHCSAs that have several sites within a region will be counted as one contract even if the plan holds separate contracts for each county with that LHCSA. However, each agency that might be part of an Independent Practice Association (IPA) will be counted as a separate contract. Plans will be required to certify compliance annually, and DOH will verify adherence to the limits at the time of a plan’s annual certification.
Plans that terminate a LHCSA contract are required to notify members receiving services from that LHCSA within 15 days of notifying the agency. Members served by LHCSAs that were terminated prior to the guidance must be notified within 15 days of the date the guidance was issued. The notice must list contact information for Medicaid Choice and inform members about options they may have to stay with their current aide, including changing to a different LHCSA, changing plans, or requesting a continuity of care exception, if applicable.
The guidance lists a number of factors, in addition to quality and value, that MTLC plans should consider when implementing the limits. These include commitment to value-based payment (VBP), training, and quality assurance; compliance with wage mandates and reporting requirements; and a willingness to hire aides to ensure care continuity. A plan must maintain network adequacy so as to have no less than two LHCSAs accepting new enrollees in each county and is required to document network adequacy to DOH if it terminates 25 percent or more of its LHCSA contracts in any six-month period.
Plans seeking to use the provision that allows them to continue to contract with an agency that is not counted against their limit for three months based on a member's wish for continuity of care must notify DOH. A plan may also request an exception to the limit based on the need for special services or services that are culturally or linguistically appropriate by demonstrating the need to DOH. Requests not denied by DOH within 30 days of receipt will be deemed granted for one year.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841 or Meg Carr Everett, meverett@leadingageny.org, 518-867-8871