Managed Long Term Care – Dual Eligible Medicaid Home Care



Homecare managed by the private sector

Recent changes to the Medicaid Home Care program (driven by a hoped for cost saving) requires all “dual eligible” applicants (receiving Medicare and Medicaid) and others upon approval for home care services to select and enroll in a Managed Long Term Care Plan (“MLTC”) run by a number of approved providers.  The Medicaid program pays the provider a fixed fee per enrolee (“capitation”) and the MLTC determines the level and kind of services the enrolee requires.

Those who where were receiving Medicaid home care before MLTC became mandatory will continue to receive the same kind and level of services without change for at least 60 days.  New enrolees, however may find that the kind and level of services are limited because of the strong incentive of the plan to minimize expenses and maximize profit.

More importantly for all, however, the first level of appeal from the services decision is to the plan itself (the wolf guarding the hen house?); after the internal appeals are exhausted an appeal (a “fair hearing”) to the state Department of Health is possible.  In any event, the MLTC approach bodes ill for seniors and their families; look out for extended struggles to obtain the services needed.

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