Affordable Care Act - Legal Services for the Elderly, Disabled and
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Transcript 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)
directly
Most services did not
require prior approval of
the plan
(Managed Long-Term Care Plans)
network
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
Plans
Partially-Capitated LongTerm Care Plans
Fully-Capitated Long-Term
Care Plans
Cover certain Medicaid
Cover all Medicaid and
services only: long-term
care
Will be mandatory plan for
Duals needing Long-Term
Care
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
network
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
automatically.
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
mailed:
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
County
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