powered by LeadingAge New York

DOH Processing Next Batch Disenrollment from MLTC

The Department of Health (DOH) will process the next round of batch disenrollments of long-stay nursing home residents from Partially Capitated Managed Long Term Care (MLTC) plans on Feb. 1, 2022. Unless the individual intends to return to the community or requests a fair hearing, residents meeting the four criteria listed below will be transferred to Medicaid fee-for-service (FFS) effective Feb. 1st:

  • Resident is enrolled in a Partially Capitated MLTC plan;
  • Resident’s status is identified as a long-term nursing home stay (LTNHS) (i.e., LDSS-3559 or equivalent provided to resident and submitted to local department of social services (LDSS));
  • Resident has been in a LTNHS for more than three months (LTNHS 3+); and
  • Resident has been determined by the LDSS to be financially eligible for nursing home Medicaid coverage.

This batch process is expected to impact approximately 1,000 individuals. The process will establish the required entries in the Principal Provider Subsystem in the Welfare Management System (WMS) to initiate Medicaid FFS coverage for these individuals and direct payment to the nursing home. The Feb. 1, 2021 Dear Administrator Letter (DAL) outlining the process is available here.

The change in the long-term nursing home care benefit has no impact on rehabilitative, short-term, or temporary nursing home residents and does not impact Program of All-Inclusive Care for the Elderly (PACE) participants, Medicaid Advantage Plus (MAP) members, or mainstream Medicaid managed care enrollees.

As with the prior cycles, the shift was preceded by a request that plans and providers assist in identifying residents who meet the disenrollment criteria but have an active discharge plan to transition to the community. Such residents should not have been disenrolled, and DOH should be notified via MLTCNH@health.ny.gov if that occurred. An active discharge plan means that the resident’s care plan has current goals to make specific arrangements for discharge and/or staff are taking active steps to accomplish discharge.

New long-stay nursing home residents are no longer required to enroll in MLTC, and enrollment in Partially Capitated MLTC plans is limited to three months for nursing home residents after their designation as being in a LTNHS unless the individual requests a hearing. The three-month benefit period begins on the first day of the month following the month of the effective date of the LTNHS designation documented by the nursing home, in conjunction with authorization by the MLTC plan, on the LDSS-3559, “Residential Health Care Facility Report of Medicaid Recipient Admission/Discharge/Readmission/Change in Status,” or an approved local equivalent.

If you encounter problems with the process, please let us know.

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841