Disenrollment of Nursing Home Residents from MLTC
The Department of Health (DOH) is preparing to implement a third round of batch disenrollments of long-stay nursing home residents from partially capitated Managed Long Term Care (MLTC) plans effective April 1st. Unless he or she is working toward returning to the community or requests a fair hearing, a resident meeting the four criteria listed below will be transferred to Medicaid fee-for-service (FFS) on April 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 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 additional “Batch Process” will disenroll individuals who now meet the above criteria and were not included in the August or November 2020 disenrollments. 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. 1st Dear Administrator Letter (DAL) outlining the process is available here.
As with the prior cycles, DOH is requesting that nursing homes assist in identifying residents who meet the disenrollment criteria but have an active discharge plan to transition to the community. Such residents will not be disenrolled. 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. The DAL provides a more detailed definition.
Nursing homes are asked to complete the Excel template provided by DOH (available for download here) listing any residents that should not be disenrolled because they are actively working toward discharge. The list should be submitted through the Health Commerce System (HCS) using secure file transfer to the MLTC Nursing Home shared mailbox. Instructions for using the secure transfer application are available here. DOH requests that this be completed by Mon., Feb. 15th.
Providers that do not have any residents who fit the above criteria of an active discharge plan are asked to notify the Department via MLTCNH@health.ny.gov that they have completed a review and do not have any members who meet the criteria.
Members will recall that new long-stay nursing home residents are no longer required to enroll in MLTC and that enrollment in partially capitated MLTC plans is now limited to three months for nursing home residents after their designation as a LTNHS. 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.
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.
Individuals being disenrolled will receive a notice (available here) from New York Medicaid Choice at least 10 days prior to disenrollment.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841