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MLTC Partial Cap Contract Webinar Highlights Changes

In a webinar on Jan. 8th, the Department of Health (DOH) summarized changes in the recently approved model contract between managed long term care (MLTC) plans and the State. Many of the changes incorporate pre-existing statutory, regulatory, or policy requirements into the model contract. Key changes in the contract, which covers the period from Jan. 1, 2017 through Dec. 31, 2021, relate to:

  • Requirements associated with changes in an MLTC's population or service area, and changes due to a merger or acquisition;
  • Program integrity, audit, and overpayment provisions;
  • MLTC eligibility determination procedures;
  • Indian health care;
  • Compliance with the federal home and community-based services (HCBS) settings rule requirements;
  • Compliance with the federal person-centered service planning (PCSP) requirements;
  • Reporting of all enrollees assessed by the plan prior to enrollment and submission within 10 business days of the end of the month;
  • Grounds for enrollee disenrollment;
  • Enrollee incentives and marketing;
  • Minimum care management requirements;
  • Advance directives counseling;
  • Emergency preparedness;
  • Assistance with discharge planning and Money Follows the Person;
  • MLTC option to provide or arrange for alternative services and settings;
  • Provider display of plan marketing materials and steering to particular MLTC plans;
  • Appeals and grievance processes;
  • Encounter data reporting; and
  • Cultural and linguistic competence requirements.

The slides from the webinar are posted here. A draft of the new contract is available here. Some of the new contract provisions are:

Changes in Service Area or Age Groups: Under the new contract, MLTC plans that alter or cease operations must receive DOH approval and comply with specific notice requirements. Other plans must accept all enrollees affected by the change and need not conduct an assessment prior to enrollment. The receiving plan must continue the enrollee's PCSP for 120 days after the effective date of the enrollment or until the plan's assessment is complete and a new PCSP is accepted by the enrollee.

To expand its service area or modify the age groups it serves, a plan must seek the approval of DOH. Changes in a service area cannot be initiated until DOH approves a transition plan and enrollee notices. Plans must also notify affected enrollees of any change in the age groups they serve.

Program Integrity, Audit, and Overpayments: The new contract contains a broad array of program integrity provisions, and plans are advised to review them carefully. Among the new provisions are a requirement to implement a compliance plan consistent with the New York State Social Services Law, Part 521 of the Social Services regulations, and federal regulations (42 C.F.R. 438.608); to submit a quarterly Provider Investigative Report; to return overpayments of premium or other funds within 60 days of identification; to implement a fraud prevention plan if the MLTC has more than 10,000 members; to submit overpayment recovery reports if the plan has fewer than 10,000 members; to implement procedures to verify the delivery of billed services; and to refer potential fraud, waste, and abuse to DOH and the Office of the Medicaid Inspector General (OMIG). Providers may be charged a collection fee if OMIG or the plan incurs costs in collecting the overpayment. In the event of a plan's participation in a fraud or abuse recovery, the contract sets forth terms for the plan's eligibility to retain a percentage of funds. Plans must also have a mechanism for providers to report overpayments and return them within 60 days of identification. If a plan fails to report or reports inaccurately funds recovered, it may be subject to liquidated damages.

The new contract also authorizes OMIG to impose penalties on plans based on misstatement of facts in their cost reports. In addition to the penalty, the amount of the misstatement must be included in the plan's next cost report as a prior period cost adjustment.

Enrollee Incentives: Plans may offer enrollees incentives in exchange for meeting a health goal, such as timely completion of an immunization, subject to DOH approval. Incentives may not be convertible to cash and may not be referenced in pre-enrollment marketing materials.

Care Management: Plans must offer care management services on a 24/7 basis. Enrollees who are permanently placed in a nursing home are exempt from care management requirements. However, plans must provide at least monthly care management contacts with any enrollee who expresses an intent to return to the community and must continue to provide Uniform Assessment System (UAS) assessments to permanently placed enrollees.

MLTC-Provider Relationships: Providers may provide prospective patients/enrollees with a list of the MLTCs with which they contract but may not steer individuals to a particular plan or product. Prospective patients/enrollees must be directed to the enrollment broker for information about plans. Providers may not display plan marketing materials.

Encounter Data Reporting: Plans are required to submit encounter data twice monthly, not more than 15 days from the date of the adjudication of the claim.

Effective Dates: Although the new model contract was only recently approved by the Centers for Medicare and Medicaid Services (CMS) and is still in the final stages of execution, the contractual changes are effective as of the effective date of any statute, regulation, or policy guidance upon which they are based. Any new requirements that do not arise from a pre-existing statute, regulation, or policy are effective as of the date of execution of the new contract.

Plans are encouraged to review the new contract thoroughly. Additional guidance describing policy, documentation, and handbook requirements will be issued by DOH.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124