How do I enroll in a managed long-term care (MLTC) plan?

Most New Yorkers obtain long-term care services through the State’s Medicaid
program. New York State requires dual-eligible adults (people who are eligible for
both Medicare and Medicaid) who want to apply for long-term care services to
enroll in a managed long-term care (MLTC) plan. Below is more information on how to enroll and what you will need.

What is the New York Independent Assessor (NYIA)?

• NYIA conducts independent assessments, provides practitioner orders, and performs reviews of high needs cases for those seeking long-term care services like home care. Maximus/NY Medicaid Choice is the contractor that runs NYIA.
• Individuals who want to enroll in an MLTC plan must first contact NYIA for an assessment and a clinical appointment. They must call 855-222-8350.

What are the eligibility requirements to join a MLTC plan?

• In order for NYIA to find you eligible to join a MLTC plan, you need to show that long term care services are medically necessary and that you need these services for at least 120 days

• Additionally, your medical condition must be stable. Medical stability means that your condition is not expected to exhibit sudden deterioration or improvement and the condition does not require frequent medical or nursing judgment to determine changes in your plan of care.
• You must also be self-directing, which means that you are capable of making choices about your everyday tasks, you understand the impact of the choice, and assume responsibility for the results of the choice. If you are not self directing, you must have another adult who can direct care for you within or outside your household (typically a spouse, relative, power of attorney/health care proxy, or legal guardian).

What should I expect once I call NYIA?

• NYIA will schedule 2 appointments with you. The first appointment is for an initial Community Health Assessment (CHA). The second appointment is a clinical appointment. The two appointments must be scheduled and completed within 14 days of you calling them. They can be conducted in-person or via telehealth.
• NYIA will only conduct the initial assessment process for individuals with Medicaid (the only exception is for Immediate Need requests). They will not schedule an assessment if your Medicaid application is still pending.
• The CHA is used to determine eligibility for enrollment into a MLTC plans and voluntary transfers from a Medicaid mainstream plan to a MLTC plan. The CHA is completed before the clinical appointment. If the CHA doesn’t happen on the scheduled date, the clinical appointment will be rescheduled.
• The clinical appointment is when you meet a clinician who will review the CHA, examine you, determine whether you meet the requirements to join a MLTC plan, and complete a Practitioner’s Order.
• The assessment and Practitioner’s Order are valid for 12 months for both home care service authorizations and MLTC eligibility purposes.
• Once the two appointments are completed, NYIA will mail you a letter with a determination on whether you are eligible for MLTC enrollment and what to do next. If you are not enrolled in a Medicaid mainstream plan, you will be advised to contact NYIA for next steps.

What documents should I provide NYIA?

• If you want someone to act on your behalf, you should complete an authorized representative form and fax it to NYIA at 917-228-8601. The form can be found here: https://nyia.com/content/dam/digital/united-states/newyork/nymc-ia/language-masters/en/pdf/MM-CF-0822.pdf.

• If you want to give your medical providers permission to share your health information with NYIA, you need to fill out a consent form that is found here: https://nyia.com/en/consent
• Have a doctor’s letter and other medical documents available and try to provide them to the assessor during CHA or clinical appointment and keep copies of documents provided.

I received a NYIA notice approving MLTC enrollment. Now what?

• You can call NYIA to discuss your options to join a MLTC plan or visit https://www.nymedicaidchoice.com/choose/find-long-term-care-plan.
• If you contact a MLTC plan regarding enrollment, the plan will develop a plan of care after reviewing the CHA. If the plan determines that you require more than 12 hours a day of home care, they will refer your case back to NYIA for a third assessment.
• After you choose an MLTC plan and sign enrollment paperwork, the plan must submit the enrollment paperwork to NY Medicaid Choice/Maximus, the entity responsible for processing Medicaid plan enrollments. If the enrollment paperwork is submitted by the 18th of the current month, then the MLTC enrollment will be effective the first of the month. For example, if the MLTC plan submits enrollment paperwork to NY Medicaid Choice on February 17th, the plan enrollment should be effective March 1st. If the paperwork is submitted after the 18th of the current month, then coverage will be effective the first of the following month. For example, MLTC plan submits enrollment paperwork to NY Medicaid Choice on February 21st, the plan enrollment should be effective April 1st.

What should I do if NYIA says I’m not eligible for MLTC enrollment?

• NYIA must provide written notice to you explaining why you were found ineligible for MLTC enrollment.
  
  You can appeal a denial from NYIA within 60 days from the date of the notice by requesting a fair hearing through the Office of Temporary & Disability Assistance, https://otda.ny.gov/hearings/request/
• After you request a fair hearing and have a fair hearing number, you can request an evidence packet from NYIA by emailing your request to [email protected], faxing it to 917-228-8899, or mailing it to Record Access Unit, NY Medicaid Choice, PO Box 5016, New York, NY 10274.
• You should call Legal Services NYC’s helpline number at 917-661-4500 to request legal assistance with your NYIA denial.
  

What if I need help with only housekeeping services?

• Individuals who only require assistance with housekeeping tasks do not meet eligibility criteria for enrolling in an MLTC plan. If this applies to you, you should still go through the NYIA assessment process. You will most likely receive a NYIA notice saying that you don’t meet MLTC eligibility.
• Upon receipt of the notice, do not request a fair hearing. Instead, you should reach out to the Human Resources Administration and say that you would like to receive help with housekeeping and that you received a notice from NYIA denying your request for MLTC enrollment. You have to fax the NYIA notice to the Human Resources Administration. If you lose your copy, you should request another one from NYIA.
• To request assistance with housekeeping, you should contact: HRA Central Intake, Tel: 929-221-8851 and 929-221-8889 and Fax: 212-666-1459

What if I need home care services right away?

• Immediate Need applications can be submitted to the Human Resources Administration if you need home care services immediately. In this instance, you do not contact NYIA directly for immediate need requests.
• Immediate need requests require a complete Medicaid application and supporting documents for those who don’t have Medicaid coverage in place, in addition to, Practitioner Statement of Need (DOH-5779), and Attestation of Immediate Need Form (DOH-5786). The entire Immediate need request has to be submitted to HRA Home Care Services Program via fax 917-639-0665.
• If you try to request immediate need home care on your own and you encounter problems or delays, call Legal Services NYC’s helpline number at 917-661-4500 to request legal assistance.

For free legal help, call Legal Services NYC at 917-661-4500 Monday through Friday from 9:30 a.m. to 4 p.m. Learn more about our intake process here.

* The information does not constitute legal advice. You should always consult an attorney regarding your matter. Legal help subject to capacity and location.