Affordable Care Act - Legal Services for the Elderly, Disabled and

Changes to Medicaid
 Because of the Affordable Care Act, many more
people will be eligible for Medicaid after January 1,
2014. Medicaid will be expanded and available to
thousands more in New York State.
 But that is not the only change to Medicaid in New
York State. New York State is changing the way it
provides services for those who have Medicaid and
need long-term care: Managed Long Term Care
The Old System vs. The New System
Old Model
(Fee for Service)
New Model
 Clients used any provider
 Providers must be in-
that accepts Medicare or
Medicaid – not limited to
any network
 Provider bills insurance
(Medicaid and Medicare)
 Most services did not
require prior approval of
the plan
(Managed Long-Term Care Plans)
 All services and specialists
must be approved by a
Primary Care Provider
 The provider bills the
managed care companyNOT Medicaid or Medicare
 The Plan gets a “capitation
rate,” an amount of money
per patient every month.
Kinds of Managed Long-Term Care
Partially-Capitated LongTerm Care Plans
Fully-Capitated Long-Term
Care Plans
 Cover certain Medicaid
 Cover all Medicaid and
services only: long-term
 Will be mandatory plan for
Duals needing Long-Term
 NO Medicare coverage
 Members continue to use
original Medicare cards or
Medicare Advantage Plan
and regular Medicare card
for primary care and
inpatient hospital care
Medicare Services
 NOT mandatory to enroll
 Must use providers within
 PACE plans offer services
through a particular site
and enrollee must be 55+
Managed Long-Term Care
 New York has had managed long term care plans for
many years.
 Before now enrollment was voluntary.
 NOW in Erie county- all people:
 over the age of 21
 who are eligible for both Medicaid and Medicare
 who require over 120 days of nursing-home level care
ARE REQUIRED to enroll in a Managed Long Term Care
Plan within the next month or so. Those who do no
enroll themselves will be enrolled in a plan
Managed Long-Term Care
 All those in Erie County who already have Medicare
and Medicaid and are already receiving over 120
days of nursing-home level care will receive a series
of letters from New York Medicaid Choice, also
known as MAXIMUS, the company hired by New York
State to handle MLTC enrollment.
 Over 1000 people in Erie county will receive these
letters this week:
New York State Managed Long-Term
Care Announcement Letter
This Letter is simply informing the individual that changes to their
Medicaid are coming.
The Next Step…
 60-Day Choice letter - About 15-30 days after
receiving that letter- another letter will be
 Requiring them to join one of the Managed
Long-Term Care Plans within 60 days
 Or they will be randomly assigned to an MLTC
plan. The letter will include:
 Guide to MLTC
 CONTACT LIST for plans :
Managed Long-Term Care Plans in Erie
 Catholic Health Life (55+ only)
 Centers Plan for Healthy Living
 Fidelis Care at Home
 Total Aging in Place Program
 Wellcare Advocate MLTC
 United Choice MLTC
Picking a Plan
 Make a list of the agencies and other providers you
want to see after you join a Plan. You can keep or
change the providers you have now.
 Which Plans work with the home care agency and
other providers you want ?
 New York Medicaid Choice can help you find out
what Plan fits the best for your needs:
 1-888-401-6582
 You have the right to choose the Plan that best
meets your needs.
Picking a Plan
 A nurse who works for the Plan will come to your home
and do an assessment to determine what services and
how many hours the new plan will provide you. This is
called a Plan of Care.
 The assessment will last a few hours. You will be asked
questions about your daily tasks and your abilities.
 You have the right to have a family member or any
advocate there with you during this assessment.
 You do not have to decide right then if you want to sign
up for the Plan.
 You have the right to see the Plan of Care before
enrolling in any Plan
90 Day Transition Period
 All Managed Long-Term Care Plans MUST provide
the same services and the same number of hours
that you have been previously been getting for 90
Days after the switch, regardless of what the Plan
determines is your Plan of Care.
 They must allow you to use with the same home
care agencies and aides that were helping you
before for 90 days or until an assessment is donewhichever is longer.
After the Transition Period
 After the 90 days, the Plan can reduce or end the
services you had previously received.
 The Plan also may not work with the home care
agencies and aides you have been using.
 The Plan will give you a WRITTEN NOTICE stating the
amount of home care and other services they will
begin to give you on Day 91 of your enrollment (after
the Transition Period is over). This may be differentless or more- than you have been receiving before.
What Can I Do?
 Legal Services for the Elderly, Disabled, or Disadvantaged of
Western New York can help you through this process if:
 You are confused about what plan or type of plan is best for you
 You were mandatorily enrolled in a Plan but want to be in a
different plan
 You do not feel you were assessed fairly or accurately by the
Plan’s nurse and do not agree with the Plan of Care
 You have received notice that your services or hours are being
reduced and want help appealing that decision
 Any problems with the Plans- such as aides being late, missed
transportation, case managers being unavailable.
 You have any other questions or problems about these changes
to your Medicaid