Is enrollment in a Managed Long Term Care Plan voluntary?
You may voluntarily enroll in an MLTC plan if you meet the enrollment criteria If you are eligible, you can choose to enroll in an MLTC plan rather than receive long term care services in other ways. For certain populations in New York City, MLTC is now a mandatory program. This means that people who are receiving long term care services from other types of programs must enroll in an MLTC plan in order to continue receiving those services. New York State is notifying those people who will be required to enroll in an MLTC directly, by letter. You will receive a list of available plans and information about MLTC plans with this letter. For those who will be required to receive their long term care services through an MLTC, you will still have an opportunity to enroll in the MLTC plan of your choice. If you do not pick a plan by 60 days from the date of the mandatory notice, one will be selected for you. If you receive a mandatory letter you should call Maximus (the enrollment broker) at the number on the letter to enroll in an MLTC plan, or to get answers to your questions. You can call UnitedHealthcare Personal Assist at 1-855-345-MLTC (6582) to learn how to enroll in the Personal Assist plan. A representative will contact you to schedule an appointment to conduct an eligibility and health assessment.
To begin the process of enrolling in a MLTC plan, you or someone on your behalf (family, friend, doctor), can contact the MLTC plan to express interest in the program. MLTC intake staff will ask you a few questions to see if you meet the basic eligibility requirements. Just call 1-855-345-MLTC (6582), and we will contact you to schedule an appointment.
If you are eligible and would like to continue with the enrollment process, we will schedule a nurse to come to your home to perform a nursing assessment and to:
- explain the rules and responsibilities of plan membership;
- determine your eligibility for the plan;
- give you a copy of the member handbook and the provider network;
- assist you with completing the enrollment application process;
- assist you with completing a Medicaid application, if needed;
- help you choose providers from the network of providers associated with the plan;
- set up a care plan with you by discussing your needs; and answer any questions you may have.
The plan will involve family members or other persons who you would like to be involved in your care. The care manager also will speak with your doctor about your care and services.
If you would like to enroll in our MLTC program but do not have Medicaid, we can assist you with that process. Once your Medicaid has been approved, we can then proceed with the MLTC enrollment process.
The plan will submit your application to the state’s enrollment broker and if your enrollment is approved, the plan must accept you. If your enrollment is denied, your rights will be explained to you.
If you have received a mandatory enrollment letter from New York State, you should review the MLTC information provided with the letter and contact Maximus to select an MLTC plan. They can also provide you with information to assist you in selecting a plan. If you do not select a plan within 60 days, one will be selected for you.
You may join an MLTC plan if you:
- have a chronic illness or disability that makes you eligible for services usually provided in a nursing home;
- are able to stay safely at home at the time you join the plan;
- are expected to need long term care services from the plan;*
- are at least 18 years of age;
- live in the plan’s service area;
- have, or are willing to, change to a doctor who is willing to work with the plan; and
- are Medicaid eligible.
*all potential MLTC members must meet clinical eligibility criteria in order to enroll in an MLTC plan. An RN will visit a potential enrollee in their home to complete a clinical assessment. If the assessment indicates that you are eligible for the program and you wish to proceed, the RN will complete the enrollment documentation, including an initial plan of care. Just call 1-855-345-MLTC (6582), and we will contact you to schedule an appointment.
Before you join or enroll in a managed long term care plan, the plan is required to provide you with a member handbook. The member handbook explains the plan’s specific services, policies, and your member rights and responsibilities.
You should review the plan’s member handbook and ask questions before enrolling in the plan. You can also call the plan’s member services department for additional information about the plan.
What are covered services?
MLTC plans arrange and pay for a large selection of health and social services. The plans can coordinate and arrange all the services you may need. MLTC plans offer services in addition to those usually paid for through Medicaid. Each MLTC plan arranges and pays for a set of specific services called “covered services”. Covered services are described in the plan’s member handbook and other plan materials. You may receive the covered services as long as services are medically necessary, that is, they are needed to prevent or treat your illness or disability.
MLTC plans arrange and pay for the following health and long term care services (as long as they are medically necessary):
- Care Management
- Home Care, including Nursing, Home Health Aide, Occupational, Physical and Speech Therapies
- Medical and Surgical Supplies
- Dental Services
- Rehabilitation Therapies
- Audiology/Hearing Aids/Hearing Aid Batteries
- Respiratory Therapy
- Nutrition and Nutritional Supplements
- Medical Social Services
- Personal Care (such as assistance with bathing, eating, dressing, etc.)
- Podiatry (foot care)
- Nonemergency Transportation to Receive Medically Necessary Services
- Home Delivered and/or Meals in a Group Setting (such as a day center)
- Medical Equipment
- Social Day Care
- Prostheses and Orthotics
- Social/Environmental Supports (such as chore services or home modifications)
- Personal Emergency Response System
- Adult Day Health Care
- Nursing Home Care
- Consumer Directed Personal Assistance Services (effective Nov. 1, 2012)
The following services are considered coordinated services, which would be paid for by either fee-for service Medicaid, or Medicare if you have it. (Although they are not services covered by the plan, your care coordinator can assist in coordinating these services for you):
- Primary Care and Specialty Doctor Services
- Outpatient Hospital/Clinic Services
- Laboratory Services
- X-Ray and other Radiology Services
- Chiropractic services
- Chronic Renal Dialysis
- Emergency Transportation
- Mental Health and Substance Abuse Services
- Prescription Drugs
Care coordination/management is a process to assist enrollees to access necessary covered services as identified in the care plan. It also provides referral and coordination of other services in support of the care plan. Care coordination/management services are available to all MLTC enrollees and will assist enrollees to obtain needed medical, social, educational, psychosocial, financial and other services in support of the care plan irrespective of whether the needed services are covered by the plan. The plan will provide a care coordinator or care coordination team for you. The care coordinator or care coordination team will be a key contact while you are in the plan, and will work with you and your doctor to decide the services you need and develop a care plan. The care plan is a written description of your services and how they will be provided. The MLTC plan can also arrange appointments for any services, inside or outside of the plan, and will arrange and pay for necessary transportation to those services.
There is no doctor (PCP) network in an MLTC plan because acute services are not a benefit of MLTC plans. Acute services which include such things as doctor’s visits, inpatient hospital stays, drugs and laboratory tests are paid for through either fee-for-service Medicaid and/or Medicare if you have it. Because of this, you do not have to change your doctor, as long as he/or she agrees to work with the plan to manage your plan of care.
In most cases you have to use services providers who are part of the plan’s network. You can get a complete listing of the plan’s network of service providers, and the languages they speak from the plan. If the service you need is covered by the plan, you will choose a provider from the plan’s list of providers. If the plan does not cover a service, you may continue to choose your own provider and use your Medicare and/or Medicaid card to obtain that service. If you received a mandatory notice and are joining a plan, you will have a 60 day transition period from your date of enrollment during which your current hours of service will continue. The MLTC plan will have 30 days from the date of your enrollment to visit you to complete an assessment.
The plan understands the importance of maintaining the relationship you have with your aide As part of the enrollment process, you agree to utilize in network providers for covered services. If your aide works for a provider who is in our network there is a good chance that you can continue your relationship with your aide. We recognize that it is often in your best interest to maintain your existing relationship with service providers and will try to accommodate your request, whenever possible. In certain cases we may work with providers outside of our network in order to maintain existing service relationships. If you received a mandatory notice and are joining a plan, you will have a 60 day transition period from your date of enrollment during which time you may keep your current services. The MLTC plan will have 30 days from the date of your enrollment to visit you to complete an assessment.
How do I get or change services?
You or your provider can ask for new or additional services (prior authorization) or more of the same services (concurrent review) at any time by calling member services who will direct your call to the appropriate person. The plan will notify you of the receipt of your request, and will notify you of their decision in writing (plan action). See member handbook for addition details regarding this process.
If you do not agree with the action that the plan has taken, you can file an appeal (See member handbook for detailed information regarding this process).
If you are appealing a reduction, suspension or termination of services you are currently authorized to receive, you may request to continue to receive these services while the plan is deciding your appeal. If an appeal is not decided in your favor you may request a Medicaid fair hearing. Information about that process will be forwarded to you with the appeal decision notice.
Who Pays for Managed Long Term Care Services?
All MLTC plans accept Medicaid. You may have to pay a monthly spend down (sometimes called a surplus) to the plan to be eligible for Medicaid. For more information about payment to the plan or Medicaid eligibility, you should review the member handbook and consult with the LDSS or HRA. The MLTC plan receives a set payment per month from Medicaid, if the plan participates, regardless of the amount or type of services you receive from the plan that month. This payment system is called “capitation.”
In New York State, you can receive Medicaid even if your monthly income is over the Medicaid limit, as long as you are willing to pay what Medicaid calls a spend-down. The monthly spend-down is an amount determined by HRA/LDSS. UnitedHealthcare Personal Assist is responsible to collect the spend-down amount from you each month.
If you have a monthly spend-down we will send you a monthly bill for the spenddown amount due. If you do not pay the amount of spend-down owed within 30 days from receipt of the bill, UnitedHealthcare Personal Assist has the right to initiate a disenrollment. The MLTC enrollment agreement that you sign to join the plan says that you understand, and agree to pay, any spend-down that is owed by you.
For services covered by Medicaid and/or Medicare that are not covered by the MLTC plan, you can continue to receive the service outside of the plan using your Medicaid or Medicare card.
MLTC plans may arrange and pay for services such as social day care or home delivered meals that are not usually paid for by Medicaid or Medicare. You do not lose any of your regular Medicaid or Medicare benefits if you join a managed long term care plan.
UnitedHealthcare Personal Assist understands that our members are part of a population with unique needs, varying cultures and educational challenges. Our Member Services Representatives speak a wide variety of languages, but if you speak a language that our staff does not know, you can ask for a translator and we will access a translation service line to assist with the call. We also can provide written information in the most prevalent languages of our members. Oral interpretation of UnitedHealthcare Personal Assist materials is also available to members in different languages.
The plan provides a TTY/TTD number (711) for hearing and speech impaired individuals, which communicates with the member services team to provide assistance to members. Member handbooks in Braille, large print and audio-cassette will be made available for members with visual impairments, and information can be read to members as requested.
Member Services can be reached at 877-512-9354 and will address other needs as they arise, including those related to physical or developmental disabilities.
How Do I Leave or Disenroll from the Plan?
You may request, at any time, to leave or disenroll from the plan. Disenrollment is the process of leaving the plan. If you choose to disenroll, you will not be able to continue to receive your current home care services. They will only be available through an MLTC plan. The disenrollment will happen as soon as possible. If you request disenrollment, your plan will submit disenrollment paperwork to the enrollment broker who must process your disenrollment. This can take several weeks. You may also choose to transfer to another MLTC plan at any time. If you wish to do so you may contact Maximus, the enrollment broker, and/or the plan you wish to transfer to and they can assist you with the process. Your current MLTC plan must continue to arrange services for you until the disenrollment takes place, and must also help you transfer to other long term care services, if indicated.
A plan may disenroll you without your permission for certain reasons. These include, but are not limited to:
- moving outside the plan’s service area;
- no longer requiring 120 days of Home and Community-based services;
- If age 18 through 20, no longer requires nursing home level of care;
- behaving in a way that prevents that plan from providing the care you need; or
- failing to pay money owed to the plan
If you need nursing home placement and are not eligible for institutional Medicaid, or refuse to agree to placement in a network facility, you will also be disenrolled from the plan. If the plan tells you it will disenroll you, and you disagree with this decision, your rights will be explained to you.
Where do I complain if I am not happy with the plan or have been denied service?
The plan’s member handbook will explain about your right to complain about the plan. If you are not happy with care or services or have been denied a service by the plan, you may file a complaint with the plan. Each plan must review and respond to your complaints and concerns. The plan will acknowledge receipt of your complaint and will notify you of the plan’s findings in writing. Medicaid may also be involved in hearing your complaint. You may also complain to the New York State Department of Health at any time. If you are not satisfied with our response to your complaint you may file a grievance appeal with the plan. Check the Member Handbook for more information.
The member handbook has telephone numbers of staff at your plan to call with either compliments or concerns. The MLTC plan also may send you a survey and ask your opinions about your care. When you answer this survey, it helps the plan to know what it is doing well and if there is anything that needs to be improved.
If you have a medical emergency: Get medical help as quickly as possible. Call 911 for help or go to the nearest emergency room, hospital, or urgent care center.
Make sure that your primary care provider knows about your emergency, because your primary care provider needs to be involved in following up on your emergency care. You or someone else should call to tell your primary care provider about your emergency care as soon as possible, usually within 48 hours.