MLTC plans and CDPAP
Managed long-term care (MLTC) is a type of health insurance in New York State available to those who are chronically ill or disabled. You must be dually eligible for Medicare and Medicaid (dual eligibility) to obtain these services.
This section explains what MLTC plans are, who qualifies for them, what services they cover, and how MLTC affects Medicaid coverage.
What is an MLTC?
In most cases, long-term care is not covered by health insurance. However, people who require managed services to assist with daily living activities can apply for specialized Medicaid programs in New York to pay for these expenses.
Managed Long-Term Care (MLTC) aims to give coordinated care to sick or disabled New Yorkers while lowering overall health care costs. The New York Department of Health also assesses applications and runs MLTC plans.
Some New Yorkers must join the MLTC. Those who fulfill all of the following criteria are required to enroll in the program:
- At least 21 years of age
- A resident of New York State
- Eligible for both Medicaid and Medicare
- Requires long-term (more than 120 days) care services due to a chronic illness or disability
New York State residents between 18 and 20 who fulfill all other criteria are encouraged to enroll. If the N.Y. Department of Health accepts your application for MLTC, you will be assigned a Care Manager. They’ll come to see you twice a year to make sure you’re getting the care you need.
What are the benefits of a Managed Long-Term Care solution?
Certain services and supplies that a plan-approved doctor determines to be medically necessary are covered by health care plans. However, these must be provided by an in-network healthcare provider, including:
- Home care, including CDPAP and any medically necessary personal care attendants, private duty nurses, home health aides, or occupational therapists
- Adult day health care (medical model and social adult day care)
- A Personal Emergency Response System (a medical device that allows you to summon help)
- Nutritional services, such as delivered meals
- Home modifications necessary to accommodate a disability
- Medical equipment and supplies, including wheelchairs, orthotics, and more
- Physical, speech, and occupational therapy outside the home
- Hearing aids and eyeglasses
- Medical care related to podiatry, audiology, and optometry
- All dental care
- Nursing home care for up to 3 months
You must use your original Medicare or Medicaid plan for other required medical treatments.
MLTC and Medicaid
MLTC plans are insurance plans that provide home care services in New York State through the Medicaid program to offer these services. If you use an MLTC while receiving care, you cannot pay for those services with your regular Medicaid card.
You can opt-in or out of the MLTC program at any time. Patients who are eligible for Medicaid but not Medicare may choose to join the MLTC program. PACE and Medicaid Advantage Plus, which are fully capitated plans, are available to patients who qualify for the MLTC program. Primary, acute, and long-term care services are
The New York State Department of Health reviews MTLC plans to guarantee that consumers receive the care they are entitled to. On the other hand, the state’s Medicaid program pays for MLTC program expenses.
The 4 types of plans
There are four types of programs, each with its own set of rules and regulations. The plan you choose will be primarily determined by whether or not you qualify for Medicare. Home care, adult day care, nursing home care, medical supplies, and transportation services are all covered by all plans.
- Mainstream Medicaid Managed Care (MMC)
If you have Medicaid instead of Medicare, your health insurance is most likely an MMC plan. These plans cover doctor visits, hospital stays, drugs, and long-term care services. You will not be obligated to join the MLTC in this situation since you do not have Medicare. That implies you will pay for all of your medical treatments with your Medicaid benefits.
- Medicaid MLTC
This is the MLTC plan’s minimum level of coverage. This plan will cover the long-term care services listed above if you have both Medicaid and Medicare. You’ll still use your standard Medicare card for doctor visits, hospital stays, and other medical treatments since you’ll keep your ordinary physician.
- Medicaid Advantage Plus (MAP)
All Medicare, Medicaid, and long-term care services are covered by MAP. While it allows you to obtain all of your care through one plan, each state’s age minimum for enrollment varies. While MAP is the most convenient program available, you must reside in a county where it is accessible in order to participate. Residents of Albany, Montgomery, Nassau, Rensselaer, Schenectady, Suffolk, and Ulster counties in New York are all qualified.
- Program of All-Inclusive Care for the Elderly (PACE)
PACE specializes in treating Parkinson’s disease and related disorders, focusing on geriatric care. Patients over age 55 can receive PACE services through Medicare, Medicaid, and long-term care. However, you will be required to get all of your treatment from a single medical facility in your community. PACE clinics are not available everywhere in New York State.
To receive long-term care services through any of these plans, you must be enrolled in Medicare or Medicaid. You will also have to be a resident of New York State and a United States citizen or legal permanent resident. In addition, you must be able to show that you need help with activities of daily living.
How do I sign up for MLTC?
To discover whether you’re qualified for MLTC and enroll in a program, you must complete two distinct steps:
- Call New York Medicaid Choice
You may call 855-222-8350 or fill out an application at www.nymedicaidchoice.com to get started. A counselor will contact you after you submit your information to help you choose a specific program and answer any concerns.
- Receive a CFEEC evaluation
The New York State Medicaid program runs the Conflict-Free Evaluation and Enrollment Center (CFEEC). Their healthcare experts examine whether individuals truly require long-term care and are therefore qualified for the MLTC program. A registered nurse from the CFEEC will come to your house for an evaluation. Your treatment plan may be set up immediately if you are determined eligible.
You may also be asked to submit additional documentation, such as a letter from your doctor or proof of your U.S. citizenship or legal permanent residency status.
Completing these steps does not guarantee that you will be enrolled in an MLTC program.
How do I change my MLTC?
Because there are several MLTC care plans to choose from, you may think you need to alter your options as your demands change, your location changes, or you get older. Patients can modify their plans; however, those with a partial MLTC plan must apply for a change within 90 days of their plan begins. After that, you may only make changes if your circumstances change significantly.