navigating managed lt care

Applying for Community Medicaid (care at home) benefits is something of a complicated process – some people navigate this independently while others seek assistance. Regardless of how you get the coverage, you still need to deal with the most important part of this process: getting needed and sufficient home care services. In recent years, the process of lining up services has become almost as difficult as getting the benefit to begin with.

So, how does Medicaid long-term care services work? In New York State, long-term Medicaid home care services are typically provided through a managed long-term care model, otherwise known as an MLTC program. The MLTC plan is an insurance company that manages the care you will receive from Medicaid. The company is paid a monthly premium (by NY State Medicaid) for each member enrolled in their plan. The premiums paid to the plan are the same for each enrollee – no matter how much (or little) care is needed.

The strategy is to put the insurance companies in charge of the care and make them financially accountable for services offered. This is a similar model to health maintenance organizations (HMOs), whereby the plan decides what services you need (or don’t need) and from whom you can obtain those services. In theory, this is a great idea as it forces plans to be more accountable for what they offer. But, the true outcome is that often people are being denied necessary services to keep the insurance company’s costs down.

The process of enrolling in an MLTC plan can be confusing. Before you can choose a plan, you must have a New York State nurse conduct an assessment of need. It may take a week or more to get an appointment. This screening assessment can run two to three hours. Once this is complete, you can move to the next step: having an MLTC plan do a similar assessment. More time waiting for an appointment and another two to three hour assessment!

In a sample case, Mary was approved for Medicaid on August 10. Her appointment with the NY State nurse was on August 18. She was approved by the state to move forward with an MLTC plan and they visited her on August 22 for another assessment.

Mary’s daughter thought she would get 24-hour coverage for her mom as she has dementia and cannot be alone. The plan assessed her and offered her only six hours a day. The tasks Mary needs help with (bathing, dressing, meals, laundry, housekeeping) could be provided in the six hours. The rest is considered “supervision” and her daughter did not understand that MLTC plans do not provide for supervision or safety. AND, since Mary was assessed after the 20th of August (the 20th of each month is the cut off for coverage to start the 1st day of the next month), she will have to wait until September 1 to receive services.

If this feels overwhelming, that’s because it is. Consider getting professional guidance to navigate this process in a less stressful and effective manner.

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