MLTC enrollment steps after your eligibility letter

The Department of Health's minimum needs guidance says the NYIA assessment "is the first step in determining eligibility" and that afterward the program "will send a notice to the member explaining next steps, including whether they may be eligible for MLTC plan enrollment (in which case they should contact NYIAP), or to contact their MMC plan to complete the care planning and service authorization process if they are eligible to receive PCS/CDPAS."

So there are two kinds of next step, and the letter tells you which:

• Managed Long Term Care route. The letter indicates you may enroll in an MLTC plan. This is usually the route for adults 21 and older who have both Medicare and Medicaid and need community-based long-term services for more than 120 days. DOH's MLTC overview says those individuals "must enroll in MLTC in order to continue receiving" those services.
• Mainstream plan route. The letter says to contact your Medicaid managed care plan, which then does care planning and authorizes services. The same DOH page notes that people who could join MLTC voluntarily may instead be authorized by their mainstream plan.

If the letter says something you do not understand, the NYIA FAQ says to call 1-855-222-8350 (TTY 1-888-329-1541). If you disagree with the results, the FAQ describes a conference and a fair hearing, the latter requested within 60 days.

DOH's overview lists what an individual must be to enroll in an MLTC plan:

• determined eligible for Medicaid by the local district or an entity designated by the Department;
• determined eligible for MLTC by the New York Independent Assessor Program using the Community Health Assessment;
• capable, at the time of enrollment, of returning to or remaining in their home and community without jeopardy to their health and safety;
• expected to require at least one covered service for more than 120 days from the enrollment date, such as nursing services in the home, therapies in the home, home health aide services, personal care services in the home (Level 2), adult day health care, private duty nursing, or consumer directed personal assistance services.

DOH adds that people assessed as needing only Level 1 services do not qualify for MLTC, and that the possibility of a hospital stay or nursing home placement during the 120 days is not counted against the person. The same page carries a table of populations excluded or exempt from MLTC, which includes, among others, people receiving hospice at enrollment, people in certain 1915(c) waiver programs, residents of assisted living programs, and people with private long-term care insurance. If any of those sound familiar, ask New York Medicaid Choice how they apply before assuming.

New York Medicaid Choice describes itself as "the managed care enrollment program of the New York State Department of Health." It is the state's official channel for choosing and enrolling in a Managed Long Term Care plan. It is not a plan, not an agency, and it does not sell anything.

• Main line: 1-800-505-5678
• Long term care line: 1-888-401-6582
• TTY: 1-888-329-1541
• Hours as published: Monday to Friday 8:30 a.m. to 8 p.m., Saturday 10 a.m. to 6 p.m.

Have the NYIA letter, the Medicaid number, and the county in front of you. If a relative will handle this, the authorized representative designation you filed for the assessment carries over; NYIA's site says the representative can "act on your behalf in all other matters with New York Medicaid Choice and the New York Independent Assessor Program." If you have not filed one, New York Medicaid Choice mails the form.

New York Medicaid Choice's site organizes long term care plans by county and by type. Its consumer pages refer to three kinds of long term care plans: MLTC Medicaid plans (sometimes called partial capitation), Medicaid Advantage Plus, and PACE. Which types and which plans are available depends on where you live. This post does not compare them; the differences involve how Medicare and Medicaid are combined, and the right places to ask are New York Medicaid Choice and, for the Medicare side, HIICAP at 1-800-701-0501.

What you can reasonably do at this step is ask each candidate plan, or ask New York Medicaid Choice to help you ask, whether your current doctors and pharmacy are in the plan's network, and how the plan handles the specific service the letter pointed to.

Choosing a plan is not the same as being enrolled. Plans typically arrange their own visit to meet the person, review the NYIA findings, and begin a person-centered service plan. The NYIA FAQ describes that plan as "a written plan created by you and your plan or Local Department of Social Services, that focuses on the needs identified by your assessment and the services and supports that are necessary to meet those needs." This is where hours are proposed. Nothing before this point sets them.

For the highest-need cases, DOH's NYIA program page notes an additional layer: when a proposed plan of care first includes services for more than 12 hours per day on average, an Independent Review Panel evaluates whether the plan is appropriate and reasonable. Families do not request this; it happens inside the process.

Enrollment is processed through New York Medicaid Choice and takes effect on a date the program confirms. Ask for that date in writing. Services usually begin after it. If you are told a start date by anyone other than New York Medicaid Choice or the plan, treat it as an estimate.

Once enrolled, the plan is your point of contact. The NYIA FAQ says assessments are done yearly unless there is a sudden and significant change in condition, and that "if you are enrolled in a plan, you must call your plan" for reassessment. Care management, service authorizations, and changes to hours all run through the plan. Disagreements with a plan's decision have their own appeal and fair hearing rights, which the plan's notices must explain.

• Treating the NYIA letter as an authorization. It is not. Services are authorized by the plan after enrollment.
• Letting an agency "handle the plan." Only the person or their authorized representative can enroll through New York Medicaid Choice.
• Skipping the network check. Confirm the primary doctor and pharmacy before enrolling, not after.
• Losing the Medicaid case in the middle. A lapsed renewal stops everything. Keep HRA (1-888-692-6116 in the city) or the county district informed of any address change.
• Waiting silently. If weeks pass with no contact after you choose a plan, call New York Medicaid Choice and ask for the status of the enrollment.