My Elder discusses how you can help your elder family members stay in their MLTC plan and what you can do if they are disenrolled
My Elder and other advocates have called on Governor Cuomo and the NYS Department of Health (DOH) to hold off on the mass disenrollment of an estimated 20,000 MLTC members from their MLTC (Managed Long Term Care) plans on August 1st. However, this mass disenrollment is going forward, with these notices being sent during the week of July 13th to most MLTC members who have been in nursing homes for three or more months. Advocates asked for the suspension of this mass disenrollment until the pandemic has ended, pointing out that visitors are still barred from entering nursing homes – with some very limited visits just beginning. This means that family, the Long Term Care Ombudsprogram, and other advocates cannot help the resident understand and appeal the notice. As far as we know and despite our requests, residents’ families or representatives are not receiving copies of the notices.
Members who have an “active discharge plan” to return home with MLTC services should not receive the notices and should not be disenrolled from the MLTC plans.
However, to identify who has “active discharge plans,” DOH relied on the nursing homes and the MLTC plans, which may have a conflict of interest and prefer that the individual remains in the nursing home, and Open Doors, which because of limited capacity helps only a small number of residents return to the community. As a result, advocates fear that many people who want to and could return home with home care will receive the notices – and will be disenrolled on August 1st unless they take action. This will force them to remain in the nursing homes, more at risk of exposure to the deadly virus.
By making it more difficult for many older people and people with disabilities to leave the nursing homes, the mass MLTC disenrollment will disproportionately harm people of color, who have suffered a more severe impact of COVID in nursing homes.
What can a representative or family member do to help someone who may be receiving this notice in mid-July, to make sure they can stay in their MLTC plan in order to obtain home care services needed to return home? BEFORE AUGUST 1ST, do one or both of the following:
1. Request a Fair Hearing. You will not be disenrolled on August 1st if you make this request before August 1st.
2. Call NY Medicaid Choice at 1 -888-401-6582 (TTY: 1-888-329-1541) to report that you have a pending request for home care services or a pending appeal or fair hearing, so you need to stay in the plan; OR call to request an assessment by the MLTC plan to return home. Either way, you will not be disenrolled on August 1st.
If the family members have any problems requesting an assessment or reporting a pending request, or other questions about this — contact ICAN at 844-614-8800 or [email protected]
What if you are disenrolled from the MLTC plan on August 1st? You can still return home but it may be more difficult to obtain the needed home care services, with more delays.
You can re-enroll in the MLTC plan within 6 months of being disenrolled, without being required to do a new Conflict-Free Assessment. This is stated in the Notice to Consumers of disenrollment. However, the State has not issued policies yet on issues such as —
1. Will the same MLTC plan you were enrolled in before be required to accept your enrollment and provide you with home care services to return home?
2. Will the MLTC plan be required to authorize at least the same amount of hours that you received before, without reducing them? We think the answer is YES under MLTC Policy 16.06 which implements court precedent including Mayer v. Wing, 922 F. Supp. 902, 911(S.D.N.Y. 1996) and Granato v. Bane, implemented in this state guidance.
If you need more hours of home care in order to return home safely, you have the right to request an increase, and if that is denied, you have the right to request a plan appeal, and then, if that is denied, a fair hearing. See Fact Sheet on Requesting Increases and Fact Sheet on MLTC Appeals and more about appeals here.
MLTC enrollment is always on the 1st of the month, so if you are ready to return home on the 10th, you will probably not be re-enrolled until the 1st of the following month.
My Elder is committed to helping our clients get the best medical care available. We can help you with elder-care services, including Assisted Living and Nursing Home Placement, Hospital and Nursing Home Crisis Intervention, Elder Care Monitoring, Elder Home Care Advisory, Long Term Care Planning, and more. Please contact us at 212-945-7550 if you need an elder advocate.
Photo Credits Sharon McCutcheon