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DOH Processes Nursing Home Resident Disenrollment

The Department of Health (DOH) implemented the third round of batch disenrollments of long-stay nursing home residents from partially capitated Managed Long Term Care (MLTC) plans on April 1, 2021. Unless the individuals intended to return to the community or requested a fair hearing, residents meeting the four criteria listed below were transferred to Medicaid fee-for-service (FFS) effective April 1st:

  • Resident was enrolled in a partially capitated MLTC plan;
  • Resident’s status was 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 had been in a LTNHS for more than three months (LTNHS 3+); and
  • Resident had been determined by the LDSS to be financially eligible for nursing home Medicaid coverage.

This “Batch Process” impacted approximately 2,000 individuals and marked the third batch disenrollment processed by DOH, with previous disenrollments occurring on Aug. 1st and Nov. 1, 2020. DOH expects to continue the batch disenrollment process at least through the end of the federal emergency, with the next cycle tentatively scheduled for July 1st. 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.

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. The DAL provides a more detailed definition.

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.

If your organization encountered problems or has concerns with the process, please let us know.

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