January 15, 2015

Medicaid Managed Care and Long Term Facilities: Mandatory Enrollment

New York State’s Medicaid program will shortly undergo a major transition that has been in the works since early 2014.  As of February 1, 2015, all individuals in need of long-term care placement in a nursing facility will be subject to mandatory enrollment in a Medicaid Care Managed Care Plan or a Managed Long Term Care Plan with a Managed Care Organization (MCO). This shift represents an expansion by New York of the use of Managed Care Organizations to administer government assistance benefits. For long-term care facilities, the introduction of mandatory MCOs will bring additional administrative measures to receive Medicaid payments for covered individuals. Instead of working with the Department of Social Services exclusively, facilities will now need to interface with DSS on eligibility and coordinate with MCOs to receive payment.

The ability to utilize MCOs to distribute public benefits began in 2011 when New York Public Health Law § 4403(f) was amended by the state to authorize the state to request CMS approval to make Managed Long Term Care mandatory.  In April 2011 the state submitted its first 1115 waiver request to CMS to make MCO enrollment for community-based long-term care services mandatory. CMS approved this request and in the past few years New York implemented the mandatory enrollment requirement for community-based long-term care services.  

New York has now requested the 1115 waiver to include mandatory enrollment for all individuals in need of long-term care placement in a nursing facility.  Originally slated to begin in 2014, the date of the transition has been moved to February 1, 2015 due to delays in CMS approval of the waiver.  The state has been divided up into three groups with staggered start dates; a facility’s start date will depend on their county.   You can click here http://www.wnylc.com/health/news/58/ to check your facility’s start date. 

Who will the Transition Affect?
The transition first affects any individual in need of long-term care Medicaid and not currently approved for Medicaid.  This means that current residents who are not Medicaid-approved and new residents seeking coverage will be required to enroll with a Managed Care Organization. Current residents who are already receiving long-term care Medicaid will be exempt from the mandatory enrollment.

Medicaid eligibility, however, will still be determined by the local Department of Social Services (DSS).  The DSS must adhere to all federal and state statutes and regulations in determining eligibility.  The process will differ slightly depending on whether the resident is already enrolled with an MCO. 

What is the role of the MCO?
The MCO is included in determining the most appropriate setting for the receipt of services, equipment and supplies.  The initial recommendation for permanent placement in a nursing home is consistent with current practice and regulations. Once a resident is approved by DSS and enrolled in an MCO the MCO will then pay the facility a negotiated flat rate for the resident. 

Following the appropriate assessments, the MCO in which the individual is enrolled is responsible for reviewing all documentation and approving or adjusting the care plan to ensure the needs of the resident are appropriately met. 

How will the transition affect Nursing Facilities?
This transition raises a number of questions and potential concerns for facilities.  By anticipating the additional administrative burden this new system will require, however, facilities can get in front of the transition and reduce as much as possible any disruption in the payment of benefits to their establishments. 

In some cases, for example, the mandatory enrollment requirement could create a delay in payment to facilities.  As an illustration of this delay, once a resident is approved for Medicaid, he or she will have 60 days to choose an MCO (or one will be assigned to the resident).  Accordingly, this can increase the time between Medicaid approval and payment for services as much as 60 days.   With this knowledge, facilities will need to make sure residents are prepared to choose an MCO immediately after Medicaid approval.

Moreover, there are no regulations that govern MCOs, unlike the DSS.  In addition, facilities will not have the ability to appeal every action or decision by the MCOs that is negative to the facility through the administrative process.  To be pro-active, facilities should pay close attention to the contracts that they negotiate with the MCOs.  These contracts will govern who applies for recertification and who collects the residents’ income (NAMI). 

To learn more please tune in to our educational webinar this Friday, January 16 at 1pm.  We will discuss other potential issues a facility can encounter with its MCOs and review best practices to increasing your involvement with the MCOs and Medicaid applications as this transition occurs. To register click here: info@cowartdizzia.com.