The Office of Medicaid Inspector in New York State (“OMIG”) has been aggressive in pursuing fraud claims against providers, targeting the problems that fee for service reimbursement create – over utilization, lack of medical necessity, upcoding and so forth.   

OMIG is also stepping up its enforcement efforts with managed care organizations (“MCOs”).  In the managed care environment, underutilization and lack of access to appropriate services can result from an MCO’s overly restrictive policies.  OMIG will review MCOs to determine whether they have conducted adequate outreach and education so enrollees know how to utilize services. 

Managed long term care (MLTC) plans are another tool in a state’s arsenal intended to help chronically ill and disabled individuals remain in the community and avoid institutional care, while helping to contain Medicaid costs.  To qualify for MLTC services an individual must be eligible for nursing home admission but be able to live safely at home at the time they join the plan.  Populations served include the frail elderly, people with physical disabilities, people with developmental disabilities, and people with severe mental illness.  MLTC plans are similar to existing Medicaid managed care plans except the capitated or partially capitated rate is paid by Medicaid in return for long term care services-typically including both nursing home care and home care- as opposed to acute care services.  Some plans accept Medicare and/or private pay in addition to Medicaid. MLTC services include:

• Care Management
• Home Care
• Rehabilitation
• Dental
• Respiratory Therapy
• Personal Care
• Meals delivered to home or in a group setting (such as a day center)
• Social Day Care and Adult Day Health Care (medical model)
• Personal Emergency Response System
• Nursing Home Care
• Non-emergency transportation

These home and community based services (HCBS) are usually less expensive than institutional care, creating an incentive for the MLTC plan to maintain its members in the community if possible.  MLTCs are mandatory in some states and voluntary in others.  With increasing long term care expenses and tight Medicaid budgets it is likely that more states will implement mandatory MLTC programs. If you are a nursing home or home care operator in New York State interested in contracting with an MLTC plan there is a directory of existing plan providers at: http://www.health.state.ny.us/health_care/managed_care/mltc/mltcplans.htm