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State Submits Waiver Amendment to Implement MLTC Eligibility Changes

The State Department of Health (DOH) has requested Centers for Medicare and Medicaid Services (CMS) approval of amendments to its Medicaid 1115 waiver to strengthen clinical eligibility requirements for managed long term care (MLTC) and to promote enrollment in integrated managed care plans for dually eligible beneficiaries. Under the waiver amendment, the eligibility criteria for MLTC will include demonstration of a need for at least limited assistance with more than two activities of daily living (ADL). For individuals with a diagnosis of dementia or Alzheimer's disease, a need for at least supervision with more than one ADL will be required. The new ADL needs requirements are in addition to the existing requirement of a continuous need for community-based long term care services for a period of more than 120 days. This heightened eligibility standard was enacted as part of the 2020-21 State Budget.

Determinations of clinical eligibility will continue to be made using the Uniform Assessment System for New York (UAS-NY) Community Health Assessment. The waiver amendment will not affect the eligibility of existing MLTC beneficiaries. Individuals enrolled in MLTC plans continuously as of Dec. 31, 2020 will remain eligible and will be reassessed using the clinical eligibility criteria applicable prior to Jan. 1, 2021.

In addition to modifying MLTC eligibility criteria, the amendment seeks to promote enrollment in integrated Medicaid-Medicare managed care products. Under the amendment, individuals dually eligible for Medicare and Medicaid who do not require long term care services (i.e., “well duals”) and who voluntarily enroll in a Medicare Managed Care Dual Eligible Special Needs Plan (D-SNP) affiliated with a qualified Mainstream Medicaid Managed Care (MMMC) plan will be permitted to remain voluntarily, or be enrolled voluntarily, in the qualified MMMC plan. It is anticipated that 6,300 well dual eligibles will remain voluntarily enrolled in the same qualified MMMC plan.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8838