Managed Long Term Care – Medicaid Home Care


New rules affect Medicaid homecare.

Applicants for Medicaid home care who are also covered by Medicare (“Dual Eligibles”), and others, are now required, upon approval for home care, to select and enroll in a Managed Long Term Care (“MLTC”) plan, including enrollment on a HMO. The MLTC selects and pays the providers and coordinates all care, including non-covered services.

Applicants have a limited number of days following the edibility approval to select a MLTC or one will be assigned randomly by Medicaid.  This decision will require investigation of the available plans, their services, an in-home assessment.  One major consideration will probably whether the applicant’s current medical providers are in-network.  Shopping around will be the order of the day.

The MLTC plans are managed by private entities that are paid on a per-capita basis (“capitation”) regardless of the kind or level of services provided. More importantly, the kind and level of services are determined by the MLTC and appeals from that determination are to the MLTC itself according to its published rules.  Only after the MLTC appeals process is exhausted can further appeal be taken to the NY State Department of Health, through the “fair hearing” procedure.

Obviously, in a capitated system, the MLTC has a financial incentive to limit the services provided.  There are procedural safeguards in place to appeal poor determinations but seniors and their families will doubtless face additional stress on top of an already stressful situation.

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