Oct 16, 2021 What Kinds of Benefits Does A Managed Long Term Care Plan Provide Under Medicaid?
What is a MLTC ?
The New York Medicaid program approves and provides Medicaid home care and other long-term care services to those who need long-term care because of an enduring health condition or disability, through monthly premium payments (also called “capitation”) to Managed Long Term Care or “MLTC” insurance plans.
The MLTC plan assumes the task that local CASA (“Community Alternative Systems Agency”) or Medicaid offices did previously, which is to determine if an individual requires Medicaid home care. This includes the number of hours to be assigned, and the arrangement of care by a network of providers with which the plan contracts. MLTC plans also approve, manage, and pay for the other long-term care services.
Which Services are Provided by the MLTC Plans?
This is what is called a benefit package of “partially capitated” plans. MLTC plans are required to provide the services in the MLTC Benefit Package detailed below, and when an individual is enrolled in a MLTC plan, they no longer use their Medicaid card for any of these services. In addition, enrollees must use providers in the MLTC plan’s network for all of these services (including a dentist). The providers will be paid by the MLTC plan and don’t bill Medicaid directly.
A MLTC Benefit Package (Partial Capitation) Plan must cover these services when they are deemed to be medically necessary. A member (enrolee) must use providers within the plan’s provider network for these services:
- Home Care, including personal care;
- Certified Home Health Agency Services, such as a home health aide, visiting nurse, visiting physical, or occupational therapist;
- Private duty nursing; and
- The Consumer Directed Personal Assistance Program;
- Adult Day Health Care;
- Personal Emergency Response System (PERS);
- Nutrition, such as home-delivered meals or congregate meals;
- Home modifications;
- Medical equipment (such as wheelchairs), medical supplies (such as incontinent pads, prostheses, orthotics, respiratory therapy):
- Physical, speech, and occupational therapy outside the home;
- Hearing aids and eyeglasses
- Four medical specialties:
- Podiatry;
- Audiology and hearing aids and batteries;
- Dental services; and
- Optometry and eyeglasses;
- Non-emergency medical transportation to physician’s offices, clinics (ambulette) was “carved out” of the MLTC benefit package effective Oct. 1, 2021, unless further delayed; and
- Nursing home care only up to three months, then disenrolled once determined eligible for nursing home Medicaid.
Which Services Aren’t Covered by MLTC Partially Capitated Plans?
- Primary and acute medical care, including all physicians other than the Four Medical Specialties listed above, all hospital inpatient and outpatient care, outpatient clinics, emergency room care, mental health care;
- Lab and radiology tests;
- Prescription drugs;
- Assisted living program;
- Hospice services – MLTC plans don’t provide hospice services but an MLTC member may enroll in a hospice and continue to receive MLTC services separately.
These services, however, are covered by “fully capitated” Medicaid Advantage Plus or PACE plans.
Takeaway
Managed Long Term Care Partial Capitation Contracts are very complex. That’s why you should work with an experienced estate planning and elder law attorney who can shepherd you through this cumbersome process.
Ely J. Rosenzveig & Associates, PC, helps individuals in the tri-state area adapt their circumstances, and implement planning strategies to help them qualify for Medicaid benefits.
Contact our experienced attorneys at Ely J. Rosenzveig & Associates P.C. either online or at (914) 816-2900. We welcome the opportunity to meet with you in person, via video conference, or by phone, and answer your questions regarding your specific health care needs, Medicaid benefits, and how we may help you to protect and preserve your assets.
