6 Jul 2018
How does Medicaid determine how much care you will get? Looking back at the time period from 2000 to 2010, the cost of home care services in New York had spiraled out of control. Most Medicaid home care was paid fee for service, which meant each service (a nurse, an aide, transportation, day care) received by a home care patient was paid individually. The more services approved, the more money providers billed to the State. In addition, each county was responsible for managing its cases and, therefore, for assessing the need for the service. As a result, these need for service assessments were not consistently measured across the counties.
As a cost saving measure, Governor Cuomo set up the Medicaid Redesign Team to try and save money. One result of this “redesign” was something called Managed Long-Term Care (a.k.a. MLTC) which debuted in New York City in 2012. The goal was to streamline the delivery of long-term home care services. Over the course of the next year or so, the program was expanded throughout NY State.
The MLTC plans are essentially insurance plans that are paid a monthly premium, capitation, by NY Medicaid to approve and provide home care (and other services) to people who need care due to a long-term illness or disability. The MLTC plans are required to use a Universal Assessment System tool designed by the state. The MLTC plans take over the job the local county offices used to do; they decide how many hours you may receive, and they arrange for the care by a network of providers that the plan contracts with. They typically cover the following care and services: personal care; adult day care; personal emergency response system; home-delivered meals; home modifications; medical equipment (wheelchairs, incontinent supplies, prostheses, orthotics); physical, speech, and occupational therapy outside the home; hearing aids; eyeglasses; and dental and non-emergency medical transportation to doctors’ offices and clinics.
The first step in getting enrolled in an MLTC Plan is having NY Medicaid Choice (a.k.a. Conflict Fee Evaluation and Enrollment Center – CFEEC) do an in-home assessment. This is a two- to three-hour assessment, but it is not a determination of services you will receive. It is just to have the State confirm you meet the qualifiers to be in an MLTC plan. Once this is done, then you can have your MLTC assessment, also two to three hours. This assessment will determine your needs and recommend hours of care and services. This is a critical assessment; if you do not present your needs appropriately, you may not get the hours of care you need. And the process of enrolling can take two to six weeks or more!
Critical to your Medicaid process is picking the right MLTC plan for your needs. This can simply be the plan that gives you the best hours of care. Or, it can be the plan that has a contract with your adult day care or the home care agency you currently use. There are so many factors that go into choosing the plan that meets your needs.
Understanding this process and navigating it successfully is critical to your plan to stay at home. Getting guidance from a Medicaid specialist can make a real difference in meeting your care needs.