By: Brian Andrew Tully, Esq. and Suzanne Paolucci, LCSW, ElderCare Coordinator
If you or your loved one is currently receiving homecare through the Medicaid Personal Care Aide Program or the Consumer Directed Personal Home Care Program (which is 99% of our Medicaid Home Care clients) things are about to change for you. The following programs are currently not effected by these changes: the Nursing Home transition and diversion program, the Traumatic Brain Injury program and the Long Term Home Health Program. Below is a brief description of what the changes are and what to expect in the next coming weeks and months. The purpose of writing this blog today was to let you know that our office is here to guide you through this process, so please do not hesitate to contact us for support.
What is the change?
The New York State Department of Health has now made it mandatory for individuals to join a Managed Long Term Care Plan if they have both Medicaid and Medicare, need home care, adult day health care, or other long term care for more that 120 days, and are 21 years of age or older. Mandatory enrollment has already occurred in Manhattan and the 5 boroughs. Long Island residents will be receiving introductory letters over the next week or two and must begin enrolling shortly after that. We recommend that you contact us upon receiving that letter so that we may assist and advocate for the most hours of care possible under the new plan.
What is Medicaid Managed Care Plan?
Managed Long Term Care Plans provide services and support to people with long-lasting health problems or disabilities. In the past, home care services were administered by the Department of Social Services. A Nurse from the Department of Social Services would assess the individual’s needs and determine the amount of hours for care. Once hours were determined, an individual would contract with a Home Care agency approved by Medicaid and start receiving services. Now, Managed Care Plans will be administering and approving the amount of home care hours needed. Each plan has its own group of home care agencies, professionals and providers. A person-centered Plan of Care is suppose to be developed. An individual will be assigned a Care Manager who will assist you in developing a Plan of Care that will meet your specific needs. All Plans provide Medicaid home care and other community long term care services. Some Plans also provide Medicare services, including doctor and office visits. If you join a plan that covers Medicare health services, you then must get your care from that Plan’s doctors and medical specialists. It is important to note that you are not required to join a plan that covers Medicare services (i.e., a Medicare Advantage plan which is an HMO type plan that generally replaces Medicare and pays for your participating doctors, hospitals and rehabilitation). You can choose to keep your current health insurance. You are only required to join a Managed Long Term Health Care Plan if you are on Medicaid. Make sure you know what plan you are signing up for.
What to Expect?
In the next few weeks you will be receiving a letter asking you to select a Managed Long Term Care Plan. Your first step will be to pick the type of Plan you want. It is important that you contact us prior to selecting a plan. You will have 60 days to make a decision and enroll by calling a telephone number provided to you in this letter. If you do not choose a Managed Long Term Care Plan one will be automatically assigned to you. During the first 60 days you have been enrolled in the new program your Care Manager should arrange for you to keep the same services you had before you joined the program. There are currently 9 Managed Long Term Care providers who will be servicing Long Island. We encourage you to contact our office to help you address any questions or concerns and guide you through this decision process. Factors to consider in the decision process should include the type of care you are currently receiving, the home care agencies you are currently receiving your care from, if you want to receive care from a medical day program, and if you want to change your current Medicare providers (Primary Care and Specialists). This is a big decision and we are here to help guide you through the process.
What if I do not like my Decision?
You may ask to change Plans at any time. Your plan must continue to arrange and pay for your services until the new Plan takes over. Disenrollment takes place at the end of the month. If you are unhappy and would like to make a grievance you can do so with your plan by phone, writing or in person. If you are unhappy with your decision, you can ask for a Fair Hearing which is a legal appeal where you should be represented by an attorney. Please contact our office if you should need assistance with any grievances or fair hearings.
The following website also discusses how to deal with grievances and fair hearings. http://www.health.ny.gov/health_care/managed_care/mltc/mltcomplaint.htm
It is important to note that you will always have certain rights. They include getting timely access to services and taking part in the decision process which can include refusing treatment. Our office is here to help insure your rights are being protected please do not hesitate to contact our office to help make sure you are getting the best care possible.
We are able to assist you in reviewing documentation, selecting the proper plan and advocating for your loved one during the assessment process.
This information is based on our understanding of current law and is for informational purposes only. It is also subject to change as we learn more about the new Medicaid Managed Care program. It is important that you discuss all legal options and consequences with a qualified elder law attorney prior to any action.