Managed long-term care (MLTC) refers to health care plans in New York State available to some chronically ill or disabled people. You must be eligible for both Medicare and Medicaid (aka dually eligible) to receive these benefits.
Below, you’ll find information on what MLTC plans are available, who is eligible, what services the plans cover, how and how MLTC affects Medicaid coverage.
What is MLTC?
Most health insurance does not pay for long-term care. However, in New York, people who need managed services to help with daily living activities can apply for special Medicaid programs to cover these costs.
Managed Long Term Care (MLTC) aims to provide coordinated care to chronically ill or disabled New Yorkers while reducing overall health care costs. MLTC plans are administered by the New York State Department of Health (NYSDOH), which also approves applications.
Some New Yorkers are required to enroll in MLTC. The plan is mandatory for those who meet all of the following criteria:
– At least 21 years of age
– A resident of New York State
– Dually-eligible for Medicaid and Medicare
– Requires long-term (more than 120 days) care services due to a chronic illness or disability
The plan is voluntary for New Yorkers between ages 18 and 20 who meet all other criteria.
If the NYSDOH approves your application for MLTC, you will be assigned a Care Manager. That person will help you work through the coordination of your care services. They will visit you twice a year to ensure you’re getting the care you need.
What is Included in Managed Long-Term Care Plans?
Care plans must cover certain services and supplies deemed medically necessary by a plan-approved doctor. These must be provided by an in-network healthcare worker and include:
- Home care, including CDPAP and any medically necessary personal care attendants, private duty nurses, home health aides, or occupational therapists
- Adult day health care (medical model and social adult day care)
- A Personal Emergency Response System (a medical device that allows you to summon help)
- Nutritional services, such as delivered meals
- Home modifications necessary to accommodate a disability
- Medical equipment and supplies, including wheelchairs, orthotics, and more
- Physical, speech, and occupational therapy outside the home
- Hearing aids and eyeglasses
- Medical care related to podiatry, audiology, and optometry
- All dental care
- Nursing home care up to 3 months
Other necessary medical services require you to use your original Medicare or Medicaid plan.
MLTC and Medicaid
MLTC plans are insurance plans paid a monthly premium by New York Medicaid’s program to provide the home care services listed above. If you receive care through an MLTC, you may not pay for those services using your regular Medicaid card.
If you have Medicaid but not Medicare, you can choose whether or not you want to enroll in the MLTC program. In addition, MLTC-eligible patients may be able to “upgrade” to “fully capitated” plans known as PACE and Medicaid Advantage Plus. These include primary, acute, and long-term care services. However, these have different requirements. However, not all doctors and pharmacies take these plans.
The NYSDOH is in charge of approving MTLC plans to ensure consumers get the care they are entitled to. However, the premiums that pay for MLTC programs are paid by New York state’s Medicaid program.
The 4 Types of MLTC Plans
There are four types of MLTC programs, and the one you choose will largely depend on whether or not you are eligible for Medicare. All plans cover home care, adult day care, nursing home care, medical supplies, and transportation services. However, other long-term care services will vary by program.
1. Mainstream Medicaid Managed Care (MMC)
If you have Medicaid and not Medicare, your health insurance likely comes from an MMC plan.
These plans cover doctor visits, hospital stays, medications, and long-term care services. In this case, you will not be required to enroll in an MLTC because you do not have Medicare. That means you will simply pay for all of your medical services with your Medicaid card.
2. Medicaid MLTC
This is the basic MLTC plan. If you have both Medicaid and Medicare, this will cover the long-term care services mentioned above. However, you will still use your traditional Medicare and Medicaid cards for your doctor visits, hospital stays, and other medical care. That also means you get to keep your regular doctor since your basic Medicare service will not change.
The MLTC programs for patients with Medicaid and Medicare that offer comprehensive (or fully capitated) medical coverage are:
3. Medicaid Advantage Plus (MAP)
MAP includes all Medicare, Medicaid, and long-term care services. While it allows you to get all of your care through one plan, each region of the state has a different age minimum for enrollment. While it is the most convenient program, you must live in a county where MAP is available in order to be eligible. MAP is limited to Albany, Montgomery, Nassau, New York City, Rensselaer, Schenectady, Suffolk, and Westchester County residents.
4. Program of All-Inclusive Care for the Elderly (PACE)
PACE offers Medicare, Medicaid, and long-term care services to patients over age 55. However, you will be required to receive all of your care from a single medical center in your neighborhood. PACE clinics are not available in every part of New York state.
How do I sign up for MLTC?
There are two main steps you need to take to find out if you’re eligible for MLTC and enroll in a program:
1. Call New York Medicaid Choice
You can call 855-222-8350 or apply online at www.nymedicaidchoice.com. Once you do this, you will be put in touch with a counselor who can help you choose a specific program and answer questions.
Before your coverage starts, your counselor will arrange for you to get an evaluation through the Conflict-Free Evaluation and Enrollment Center (CFEEC).
2. Receive a CFEEC evaluation
The Conflict-Free Evaluation and Enrollment Center (CFEEC) is run by the New York State Medicaid program. Their healthcare professionals evaluate whether patients genuinely need long-term care and are therefore eligible for the MLTC program. The CFEEC will send a registered nurse to your home for an evaluation. If you are deemed eligible, your care plan can begin.
How do I change my MLTC?
Because there are a variety of MLTC care plans, you may feel you need to change plans as your needs, location, or age change. Patients are allowed to change plans; however, as of December 2020, those with a partial MLTC plan must request a change within 90 days of when their plan starts. After that, they must wait 9 months unless they have a “good cause” for the change.
After the waiting period is up, anyone may change plans by contacting the new plan and submitting an application or calling New York Medicaid Choice at 1-888-401-6582, TTY: 1-888-329-1541.