Six months ago, I wrote about the changes in how long-term
home care services will be delivered to the elderly in New York: Managed
(“privatized, for profit”) Medicaid. The new system has begun, and it is
important that those in need of care at home and their families understand the
differences between the old and new systems. This change applies to persons
over 21 who are on both Medicare and Medicaid (“dual eligible”) and receive
more than 120 days of home care services.
The change began in New York City in October, 2012, and
in Nassau, Suffolk and Westchester counties in the past few months. Although
the County Departments of Social Services continue to determine an applicant’s
financial eligibility for Medicaid, once that approval is made, the applicant
is required to enroll in a private Managed Long Term Care (MLTC) plan. The MLTC
company is responsible for coordinating the home care services.
The MLTCs have contracted with home attendant vendors to
provide the needed services. The Medicaid program pays the MLTCs a flat monthly
amount per person for home care services, regardless of the number of hours of
care provided. Since the MLTCs and the vendors are private, for-profit
entities, there is a real concern that the MLTCs will seek to maximize profits
by approving as few hours as possible for home care and by reducing
reimbursement rates for the home attendant vendors.
Existing and new recipients of Medicaid for long-term
care services at home will need to choose an MLTC or be automatically enrolled
in one. Notices and enrollment packets are being sent to new home care Medicaid
recipients. It is expected that existing recipients will be receiving the
notices and packets during the next several months. It is recommended that
recipients obtain expert advice before choosing, since the procedure at this time
is more complex than simply choosing a plan.
Once a recipient is enrolled in an MLTC, a nurse or
social worker from that plan will visit and evaluate the recipient and
recommend the amount of hours of home care to be approved. If the recipient
does not agree with the decision, he or she must navigate a grievance and
internal appeal process within the plan. After a final determination, the
recipient may appeal the decision to the State Department of Health in what is
known as a “fair hearing”. A recipient dissatisfied with that decision has no
alternative but to file a lawsuit (as in the former process).
An important safeguard in the appeal process is that the
MLTC plan must continue providing services at the current level for up to 60
days if a request is made within 10 days after the MLTC sends a notice of
intention to reduce benefits. This continuation request has certain
requirements, but if it is done correctly, the plan may not reduce the level of
benefits, such as hours of care provided, until there has been a final
Of course, recipients will want to choose a plan in which
their providers participate. Links on the State Health Department’s website can
help recipients and their families determine what services different MLTC plans
offer. The site also has listings of the types of plans offered, a directory of
plans and performance reports. The link can be found at http://www.health.ny.gov/health_care/managed_care/choosing.htm.
The new system will allow recipients to change plans. The
change will be effective the first day of the month following the month in
which the request is made, provided that the request is made before the 19th
of the month. Making a change is not expected to be difficult. However, since
the process is new, only time will tell if problems will arise.
As I suggested above, it is anticipated that the
for-profit MLTCs will be inclined to limit services in order to make money. Since
they are being paid a fixed amount per recipient, they obviously have a direct
financial incentive to provide less care. The process of obtaining adequate
care and keeping it has become more complex. Since each particular case has its
own unique facts, the reader is cautioned that the above summary cannot be
considered legal advice and should consult with an appropriate legal advisor. As
this new program is implemented, you may expect to see further updates.