Every year, millions of Americans need access to a long term care facility. Unfortunately, those individuals – the elderly and those with chronic conditions – are often those who are least able to afford long term care. Thankfully, Medicare and Medicaid services are available to provide help to most people. These programs, collectively, are called Managed Long Term Care (MLTC).
So, how does MLTC work, and what does that mean for you? We’re about to find out.
What is Managed Long Term Care (MLTC)?
The “Long Term” in MLTC refers to healthcare that’s required for day-to-day activities. For example, if you need help getting out of bed because you’re recovering from surgery and are expected to get better, that’s not “long term” care. On the other hand, if you need help getting out of bed because of a chronic condition, that would be long term.
Long term care can be very involved or less involved. For instance, some people simply need help with house cleaning or cooking. Others require constant, around-the-clock care for severe medical conditions.
The “Managed” part of MLTC simply refers to a type of health insurance. Without getting too far into the weeds, for-profit health insurance don’t offer long term care insurance directly to the public. Instead, they partner with Medicaid to keep costs as affordable as possible.
This means that unless you’re paying out of pocket, you need to qualify for Medicare or Medicaid to receive MLTC. It also means that much like with ordinary health insurance, you’ll need to work with a provider from your plan’s network.
Because of the way private insurance, Medicare, and Medicaid interact, there’s no single type of MLTC. That said, all MLTC programs are required to cover certain services such as adult day care, home care, nursing home care, transportation services, and medical supplies.
What Kinds of MLTC Plans Are There?
In total, there are six different types of MLTC plans. While all of them must cover different types of services, all must cover the services we listed above. In addition, all plans of the same type offer the same coverage. So, for example, all MMC plans will cover the same types of care.
All MLTC plans require Medicaid. However, not all plans require you to have Medicare. For individuals with Medicaid only, you have two options: a Mainstream Medicaid Managed Care (MMC) plan, or a variant called a Health and Recovery Plan (HARP). If you have both Medicare and Medicaid, you can choose between MLTC, PACE, MAP, and FIDA-IDD plans.
If this sounds overwhelming, don’t panic! Here’s a quick breakdown of how each type of plan works.
MMC and HARP
An MMC plan provides all-in-one coverage for all of your medical needs. In addition to long term care services, it also covers the cost of doctors, medications, and hospital visits.
HARP is a variant of MMC plan that’s designed for individuals with mental health or substance used disorders. These plans are mostly different in how they’re administered. Other than that, they cover the same services as an ordinary MMC plan.
Medicaid MLTC
A Medicaid MLTC is the standard type of MLTC, which is used by most senior citizens who require long term care. This is called a partial-capitation MLTC, since it doesn’t cover all of your healthcare costs, only your long term care costs and a handful of other services.
The most important things covered by Medicaid MLTC plans are:
● Adult day care, personal care, home health aides, Consumer Directed Personal Assistance, and residential care
● Private duty nursing
● Transportation to doctor’s appointments, therapy, and other covered services
● Therapy, including physical, occupational, and speech therapy
● Home meal deliveries
● Medical equipment
● Hearing aids and related specialist appointments
● Vision care
● Dental care
As a result, patients with MLTC normally need to use traditional Medicare or Medicaid coverage for their other medical needs. This means managing two plans, which can be a downside. On the other hand, it also means you can keep your existing primary care physician, since your primary healthcare won’t change.
PACE
The last three types of MLTC are all fully-capitated plans. This means they provide not just your long-term care insurance, but also your ordinary everyday health insurance. With these plans, everything goes through your MLTC, and you would no longer need to use a Medicare card.
The upside of a fully-capitated plan is that all of your needs are covered through the same plan. Much like an MMC or HARP plan, you get all your coverage in one package. That said, when you’re signing up for a fully-capitated plan, you need to do your homework. You want to make sure your current doctor is on their network, or you’ll have to change doctors after you’ve signed up.
The most common type of fully-capitated plan is called PACE, which stands for “Personal All-inclusive Care for the Elderly.” Because it’s a combination of long term care, Medicare, and Medicaid, only people 55 years and older are allowed to join.
PACE services are offered in local neighborhood centers, where you go to receive most of your care. There, you’ll find doctors, nurses, physical therapists, daily meals, and social activities. Because this is a neighborhood-based service, it’s only available in areas where there’s a PACE center nearby.
MAP
MAP is short for Medicare Advantage Plus. In many ways, it’s similar to Medicare Advantage, where you work through a private managed care plan. The only difference is that long term care is added to the benefits.
Like PACE, MAP provides fully-capitated coverage to provide for all of your healthcare needs. However, age requirements can vary from plan to plan. Some require you to be 18 or older, while others require you to be 21, 55, or 65 years old. Also unlike PACE, services are offered through ordinary healthcare providers, not through a neighborhood center.
FIDA-IDD
FIDA-IDD is short for Fully Integrated Duals Advantage for people with Intellectual and Developmental Disabilities. This is a healthcare program for Medicare and Medicaid patients who also receive services from the Office for People with Developmental Disabilities (OPWDD). FIDA-IDD is a fully-capitated plan, just like PACE and MAP.
FIDA-IDD is designed to meet the special needs of those with intellectual and developmental disabilities. In this program, your healthcare decisions are made by a team consisting of you, family members, your doctor, and a care manager who oversees your plan. The care manager’s job is to make sure that all of your needs, like prescriptions and therapy, are all taken care of properly.
Like PACE, FIDA-IDD is only available in some parts of New York State. These areas include New York City, as well as Rockland, Suffolk, Nassau, and Westchester counties.
Who Must Join an MLTC plan?
We’ve talked about the benefits of an MLTC plan. But when would you actually have to join one? There are four requirements. If you meet all four, you must enroll in an MMC, MAP or PACE plan. The requirements are:
● You are currently enrolled in Medicare
● You are currently enrolled in Medicaid
● You are 21 years old or older
● You need long term care, adult day care, or nursing home care
If you do not meet all of those requirements, you may still get MLTC coverage. You will need to work through Medicaid and obtain PACE, Medicaid MLTC, MAP, or FIDA-IDD coverage. Medicaid recipients transitioning from Medicaid long term care to Medicare will also need to choose a plan.
How do I Sign up for MLTC?
Medicaid recipients who do not have Medicare are not required to sign up for an MLTC. They can simply apply for Medicaid long term care coverage. However, if you have both Medicaid and Medicare, or if you only have Medicare, you’ll need an MLTC to obtain coverage. Here’s how you sign up.
First, if you don’t already have Medicaid, you’ll need to sign up. Apply through your local Department of Social Services (DSS). A list of local DSS offices can be found on the website for the New York Department of Health.
You’ll have to fill out an application, provide your income, and fill out an application. You’ll also be asked to provide proof of income and of any assets you own. Decisions can take up to 45 days, although they can be expedited in certain emergency circumstances.
Since the application process can be complicated, most local DSS offices provide assistance. If you need help, instead of using the web, go to the link we provided and find the number for your local office. Call them up and ask for help. If you can’t find your county on the list, you can call the main helpline at (800)-541-2831 for more assistance.
What is the Conflict-Free Evaluation and Enrollment Center?
After you’ve signed up for Medicaid, you’ll finally be able to apply for an MLTC plan. Remember, this is a separate process. To qualify for MLTC, Medicaid recipients must be able to demonstrate that they need assistance with normal, everyday activities.
To determine whether you qualify, Medicaid will send a nurse to your home for an evaluation. They’ll sit down and talk with you, and find out about your everyday life and what you need help with. They may also examine your home to identify any obstacles to your normal activities. Currently, due to Covid-19, this evaluation can be performed over the phone or via video chat.
You can schedule your evaluation by calling your local DSS, or by calling the state hotline at (855)-222-8350. If you’re also applying for Medicaid at this time, you don’t have to wait for your application to be approved. You can get your evaluation at the same time.
Make sure to set aside about three hours on the day of the evaluation. If you’d be more comfortable having someone else present, a friend or family member can join you during the evaluation.
When the evaluation is finished, you won’t need to wait to find out if you’ve been approved. The nurse will tell you before they leave whether or not you’ve been approved for MLTC. If the answer is no, the DSS will send you a letter in the mail explaining why you were not approved, and you’ll have the opportunity to respond.
If you want to appeal the decision, you can request a hearing in front of a judge. This is a special type of hearing called a Medicaid Fair Hearing, where you can present your case to the court. If the judge rules in your favor, their decision is final, and you will be able to enroll in MLTC.
Can You Have Assets and Join an MLTC?
The purpose of Medicaid is to provide healthcare for those who are unable to afford it. For that reason, only people with limited income and assets are able to receive coverage. And because different states have different costs of living and administer their own programs, different states have different requirements.
In New York State in 2021, the maximum monthly income is $884 per month, or $904 per month for individuals who are disabled, blind, or elderly. Certain other individuals, such as people aged 18-21, their parents, and caretakers of disabled adults will also have a different income limit. Contact your local DSS or caseworker if you fall into one of these categories.
In many parts of New York, $904 per month is barely enough to get by, especially if you have medical expenses. So how does a person who earns more than that amount get coverage?
Medicaid has a program called “spend-down” that allows people to deduct most medical expenses. This program won’t help everybody, but it helps many people with high medical costs. Here are a couple of examples to show how Medicaid spend-down works.
Emily is 74 years old and earns $1,070 per month between her pension and Social Security. This puts her above the $904 income threshold. However, Emily pays $200 a month in medical expenses to manage a chronic condition. After subtracting $200 from $1,070, Emily’s income after spend-down is $870, which is less than $904.
In this case, Emily would normally earn too much to qualify for MLTC. However, after her $200 spend-down, she qualifies. However, there are a couple of caveats.
First, Emily must spend her own money until she reaches the $904 threshold. $1,070-$904 is $166, so Emily would still be responsible for $166 of her medical expenses. Once she has “spent down” to the threshold, Medicaid will cover the other $34.
Another caveat is that there’s an asset limit. For most seniors, the limit is $2,000 for an individual or $3,000 for a couple. If you own more than that, you’ll need to sell your own belongings until you qualify for MLTC.
There are some exceptions to these asset limits. Seniors who are disabled or legally blind are allowed to retain $14,850 assets if they are single, or $21,750 for couples.
Finally, only adults who are 65 or older, are disabled, or who are caring for a minor child can use spend-down. That said, most other adults wouldn’t want to. They can take advantage of Medicaid coverage, or of the Obamacare Essential Plan. These plans both come with a much higher income limit and no asset requirements.
Some people with the Essential Plan can still obtain Medicaid long term care. These are individuals aged 18-20, people with minor children, and people who are disabled.
How do I Change my MLTC?
So, you’re on an MLTC plan, but you want to change to a different one. How exactly is that done?
It depends on your coverage. If you have a fully-capitated plan, you’ll only need to change your MLTC. If you have a partially-capitated plan, you may need to change your primary healthcare as well. Here’s a quick primer.
Changing Your Basic Health Plan
Basic Medicaid plans are administered by individual counties. In most counties, you’ll have the choice between at least two plans, and sometimes more.
After you first sign up for coverage, you’ll have 90 days to change to a different plan. After that, you’ll be locked in until the end of your first year of coverage. At that point, you can switch to a different plan at any point.
When you switch plans, your “timer” will reset. You’ll once again be able to switch for 90 days, before being locked in for a full year.
In New York City, there are a few exceptions to this rule. City residents who are transgender, homeless, or HIV-positive can change plans at any time.
Changing Your Long Term Care Plan
Unlike standard Medicaid coverage, your MLTC plan can be changed at any time. To change plans, you need to contact the plan you’re interested in changing to. If you’re not happy with your current plan but not sure what you want to switch to, the New York Medicaid Choice Office provides free phone assistance Monday through Friday during business hours.
Keep in mind that plan changes take place at the end of the month. If you start a new plan on the 26th and have a visits from your nurse on the 30th, that visit will still be covered by your old plan. Starting on the first of the new month, your new plan will take over.
Note that changing your plan is not the same as changing your service provider. If you’re happy with your insurance but unhappy with your care, contact your administrator and ask to change to a different provider. Oftentimes, this can be done without changing to a different MLTC plan.
What is CDPAP?
CDPAP is short for “Consumer Directed Personal Assistance Program.” This is a Medicaid program for disabled or chronically ill New Yorkers who need home nursing assistance, or who need a home help aide for everyday activities.
Under ordinary MLTC plans, the patient signs up for long term care and the agency chooses a nurse or an aide. Under a CDPAP plan, the patient, a family member, or a friend is able to choose their own nurse or aide, giving them more control over their treatment.
CDPAP used to only be available to some MLTC recipients. Now, all counties, and all MLTC plans are required to have a CDPAP option. They are also required to notify all eligible recipients that they have the right to enroll.
Services covered by CDPAP include all services normally performed by a personal aide, a home health aide, or a nurse. Under this program, the plan is no longer responsible for hiring, training, or supervising the aide. All of those things are the responsibility of the patient, or of the patient’s family or friends.
As with qualifying for ordinary MLTC, qualifying for CDPAP requires an evaluation by a nurse. Individuals wishing to receive CDPAP coverage must also be eligible for Medicaid. Thirdly, to qualify for CDPAP, you must actually have a medical condition or disability that requires a home health aide, nurse, or other assistant.
Finally, because CDPAP patients are responsible for their own care, they must “be self-directing or, if non self-directing, have a designated representative.”
Can You Sign up for CDPAP When You Have MLTC?
Yes and no. It depends on what type of coverage you already have, and what kind of plan you’re already enrolled in.
To begin with, people with Medicaid only will normally be required to enroll in an MMC plan. MMC plans have administered CDPAP services since 2012, so you’ll need to go through them to receive CDPAP coverage.
Note that there are a few exceptions who will still receive coverage through their local DSS, such as hospice patients. Another exception is anyone who only needs help with housework, or only requires adult day care.
For individuals currently receiving CDPAP service through their local DSS, the transition process is a bit different. In this case, their plan will be administered through the DSS even if they enroll in MMC for other long term care needs. After 90 days, the MMC plan will hold their own evaluation to determine eligibility.
Applicants who already have an MMC plan can simply apply through their MMC. The same goes for individuals who already receive coverage through PACE, MAP, or FIDA-IDD.