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Nursing Home Resident Shift to FFS Scheduled for Aug. 1st

We remind nursing home members that after a two-year wait for federal approval and additional delays due to the pandemic, the Department of Health (DOH) is set to implement the second phase of the Managed Long Term Care (MLTC) nursing home benefit limit. This provision limits members of partially capitated MLTC plans who are in a long-term nursing home stay to three months of MLTC enrollment. On Aug. 1st, DOH will batch disenroll nursing home residents who meet these criteria from their plan and transfer them to fee-for-service (FFS) Medicaid. The updated Dear Administrator Letter (DAL) that DOH issued on June 11th outlines the process and is available here.

The first phase of the process occurred earlier this year when new long-stay nursing home residents not yet enrolled in MLTC were no longer required to enroll. The Aug. 1st batch disenrollment represents the second phase. After the batch disenrollment, no further disenrollments will occur until such time as DOH issues guidance for the third phase (i.e., monthly plan-initiated disenrollments of residents newly meeting the three-month criteria).

The three-month benefit period begins on the first day of the month following the date on which a resident is designated as a long-term stay resident. The designation occurs when a nursing home documents, 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” form or an approved local equivalent) that the resident has entered a long-term stay.

Residents impacted by the batch disenrollment should receive two notices (available here and here) scheduled to be mailed on July 10th and 13th. The disenrollment notice informs the individual that because financial eligibility for Medicaid coverage of nursing home care has been determined, after the disenrollment effective date, the individual’s nursing home care will be paid for through Medicaid FFS. If the individual has been paying Net Available Monthly Income (NAMI) toward the cost of nursing home care, the individual is to pay the NAMI directly to the nursing home.

The notice also provides the resident the opportunity to request an assessment to determine whether their needs can be met safely in the community. For those who request the assessment, New York Medicaid Choice will work with the individual and the plan to arrange for the assessment. Those who request an assessment before their disenrollment date will not be disenrolled from their MLTC plan until they are notified by the plan of the plan’s decision.

The change in the nursing home benefit does not apply to other MLTC products including Fully Integrated Duals Advantage-Intellectual/Developmental Disabilities (FIDA-IDD), Programs of All-Inclusive Care for the Elderly (PACE), or Medicaid Advantage Plus (MAP). It also does not apply to mainstream Medicaid Managed Care. The change in the long-term nursing home care benefit has no impact on rehabilitative, short-term, or temporary nursing home residents enrolled in MLTC.

Members should note that for new admissions and changes in status that occur following receipt of the DOH letter, nursing homes are required to provide a copy of the LDSS-3559 to the resident and any other individual representing the resident in his or her care with the nursing home. The LDSS-3559 is also required to be sent by the nursing home to the resident’s local department of social services (LDSS).

We urge members to assist residents in understanding the notice, to monitor the transition to ensure that those individuals who are being disenrolled are appropriately reflected on their FFS roster, and to ensure that NAMI payments are being routed correctly. While most providers expect the return to FFS to reduce administrative efforts and improve cash flow stability, some members who have negotiated rates that are more robust than the benchmark rates may be negatively impacted. Please contact us should your home experience a funding crisis related to this change, if you identify problems with residents reverting to the FFS Medicaid roster, or if you encounter difficulties in having NAMI payments routed appropriately.

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