Managed Long Term Care (MLTC) plans are insurance plans that are paid a monthly premium (“capitation”)  by the New York Medicaid program to approve and provide Medicaid home care and other long-term care services (listed below) to people who need long-term care because of a long-lasting health condition or disability.  The MLTC plans take over the job the local CASA or Medicaid offices used to do – they decide whether you need Medicaid home care and how many hours you may receive, and arrange for the care by a network of providers that the plan contracts with..  They also approve, manage and pay for the other long-term care services listed below.  

In addition to this article, for latest updates on MLTC –see this NEWS ARTICLE on MLTC Implementation.  

  • Free Webinar recorded April 24, 2014 on MLTC –available for online viewing  explaining Managed Long Term Care and the upcoming expansion to require new nursing home residents to enroll in MLTC plans, or, for those without Medicare, into mainstream managed care plans.  The webinar was conducted by Valerie Bogart and David Silva of the Evelyn Frank Legal Resources Program at NYLAG.

You can also view and listen to a recording of the entire webinar at this link: (2.25 hours)

The PowerPoint and Appendix used in the webinar are available at the following links:



90-Day Transition PeriodOn May 8, 2013, the State extended the time that MLTC plans must continue providing the same amount and type of home care services that new members previously received from a CASA, DSS, or CHHA from 60 days to 90 days.  Read more about the Transition Period. 

State Complaint Number for MLTC Problems – 1-866-712-7197 

  • e-mail and put “COMPLAINT” in subject line


  • In General — NYS Shift from a Voluntary Option to Mandatory Enrollment in MLTC


  • What is “Capitation” — What is the difference between Fully Capitated and Partially Capitated Plans?  What are the different types of plans?

  • Lists  of Plans – Contact Lists for NYC and Rest of State (MLTC, MAP and PACE)

  • Phased In Roll-Out SCHEDULE — Who must enroll in MLTC and in what parts of the State? When?

  • WHO DOES NOT HAVE TO ENROLL IN MLTC in NYC Mandatory Counties?  (Exemptions Exclusions)

  • Conflict-Free Eligibility Assessment – from NY Medicaid Choice

  • WHICH SERVICES ARE PROVIDED BY THE MLTC PLANS – Benefit Package of “Partially Capitated” Plans

  • ENROLLMENT:   What letters people in NYC mandatory counties receive giving 60 days to choose an MLTC PLAN

    • ​Choosing and Enrolling in a Plan – Continuity of care policy requiring all plans to contract with existing personal care/home attendant vendor agencies in NYC and other mandatory counties

  • AFTER YOU ENROLL IN MLTC –  In Mandatory Counties –Right to Continue Past Services During 90-Day Transition Period — Assessment and Changes Made by Plan,

    • Requesting new services or increased services – when must plan decide

  •  Changing Plans, and What if You can’t wait for the 1st of the next month for services?   

  • Spend-Down or Surplus Income – Special Warnings and Considerations

  • NEW SEPT. 2013 –  Spousal Impoverishment Protections Apply in MLTC

  •  The New Housing Disregard – Higher Income Allowed for Nursing Home Residents to Leave the Nursing Home by Enrolling in MLTC

In General — NYS Shift from a Voluntary Option to Mandatory Enrollment in MLTC

New York has had managed long term care plans for many years.  Before, however, enrollment was voluntary, and MLTC was just one option of several types of Medicaid home care one could choose.  Other choices included personal care services, approved by the local CASA/DSS office, Lombardi program or other waiver services, or Certified Home Health Agency services.   On Sept. 4, 2012, the federal government Medicaid agency “CMS” approved the state’s request for an “1115 waiver” that will allow NYS to require that all dually eligible  (those who have Medicare and Medicaid) adults age 21+ now receiving — or who will apply for — community-based long-term care services — particularly personal care/home attendant services long-term Certified Home Health Agency services, Consumer-Directed Personal Assistance program services (CDPAP), private duty nursing and medical adult day care  — to enroll in a  Managed Long-Term Care (MLTC) plan.  The MLTC plan will now control access to, approve, and pay for all Medicaid home care services and other long-term care services in the MLTC service package.  This is the only way to obtain these services for adults who are dually eligible, unless they are exempt or excluded from MLTC.  

If they do not choose a MLTC plan then they will be auto-assigned to a plan.   The requirement to enroll in an MLTC plan is being rolled out gradually throughout the State, starting in NYC, Long Island and Westchester and then to other counties.     See roll-out schedule for mandatory enrollment below.  People who live in counties that are not yet mandatory do not have to enroll in an MLTC plan – they may still apply for Medicaid personal care services at their local county DSS, or obtain CHHA services.

  • TIP FOR PEOPLE LIVING IN COUNTIES THAT ARE NOT YET MANDATORY:  If you live in a county that is not yet mandatory, and are content with the Medicaid home care or adult day care services you are already receiving from your CASA/DSS office, day care program, or CHHA,  we recommend not enrolling in an MLTC plan until MLTC becomes mandatory in your county.  This is because certain consumer protections apply only in mandatory counties, such as the right to a “90-day transition period,”  where the MLTC plan must continue providing your former Medicaid home care services for the 1st 90 days of enrollment in the MLTC plan.  See roll-out schedule. – many counties added throughout 2014.


NYS  DIRECTIVES, CONTRACTS, POLICY GUIDANCE — Medicaid Redesign Team page – scroll down to MRT 90 – Managed Long Term Care — documents include the following but check as often updated:  Click on

What is “Capitation” — What is the difference between Fully Capitated and Partially Capitated Plans?  What are the different types of plans? 

The monthly premium that the State pays to the plans  “per member per month” is called a “capitation rate.”  The amount of this premium is the same for every enrollee, but it is not a cap on the cost of services that any individual enrollee may receive.  Instead, the plan must pool all the capitation premiums it receives.  The rate is supposed to be enough for the plan to save money on members who need few services, so that it can provide more services to those who need more care.  To make it more confusing, there are two general types of plans, based on what services the capitation rate is intended to cover:

I.   “Partial Capitation” — Managed Long-Term Care Plans  – “MLTC” –  Cover certain Medicaid services only 

 “Managed long-term care” plans are the most familiar and have the most people enrolled.  They provide Medicaid long-term care services (like home health, adult day care, and nursing home care) and ancillary and ambulatory services (including dentistry, optometry, audiology, podiatry, eyeglasses, and durable medical equipment and supplies), and receive Medicaid payment only, with NO Medicare coverage. 

These plans DO NOT cover most primary and acute medical care.  Members continue to use their original Medicare cards or Medicare Advantage plan, and regular Medicaid card for primary care, inpatient hospital care, and other services.  The MLTC plan does not control or provide any Medicare services, and does not control or provide most primary MEDICAID care.   Managed long-term care plan enrollees must be at least age 18, but some require a minimum age of 21.  See state’s chart with age limits.

It is this partially capitated  MLTC plan  that is becoming mandatory for adults age 21+ who need  Medicaid home care and other community-based long-term care services.  But consumersl have the option of enrolling in “fully capitated” plans as well — so it’s important to know the differences.  A summary chart is posted here. 

II.   “Full Capitation” –  Plans cover all Medicare Medicaid services — PACE Medicaid Advantage Plus  

PACE and Medicaid Advantage Plus plans provide ALL Medicare and Medicaid services in one plan, including primary, acute and long-term care.  All care must be in plan’s network (hospitals, doctors, nursing homes, labs, clinics, home care agencies, dentists, etc.). For these plans, your need for daily care must be such that you would be eligible for admission to a nursing home.   When you join one of these plans, you give up your original Medicare card or Medicare Advantage card.  Instead, you use your new plan card for ALL of your Medicare and Medicaid services.  There are 2 types of FULL CAPITATION plans that cover Medcaid long-term care:

(1) PACE Programs of All-Inclusive Care for the Elderly”  plans – must be age 55+  See  CMS PACE Manual.   Link to federal PACE regs – 42 CFR Part 460. and other guidance on PACE  :   

(2) MEDICAID ADVANTAGE PLUS [MAP] – age requirements vary among plans from 18+ to 65+ 

NOTE:  MEDICAID ADVANTAGE PLANS are a slight variation on the MEDICAID ADVANTAGE PLUS plans.  They provide and control access to all primary medical care paid for by MEDICARE and MEDICAID, EXCEPT that they do not cover most long-term care services by either Medicaid or Medicare. Anyone who needs Medicaid home care should NOT join this 3rd type of plan!  

See this chart summarizing the differences between the four types of managed care plans described above.  The chart also includes a 5th type of managed care plan – Medicaid Managed Care – these plans are mandatory for most Medicaid recipients who do NOT have Medicare.  The capitated payment they receive covers almost all Medicaid services, including personal care and CHHA home health aide services, with some exceptions of services that are not in the benefit package.   

See this chart of plans in NYC organized by insurance company, showing which of the different types of plans are offered by each company as of Feb. 2013

Lists of Plans – NYC and Rest of State: 

  • Statewide County by County Chart created by NYLAG (NYC on PAGE 4) showing the number enrolled in each of the various plans as of  april 2015  2014

  • Chart organized by insurance company, which sponsors the plan, showing which different MLTC/MAP/PACE plans are offered by the company as of March 2014.  Shows which companies are launching FIDA plans in 2014.

  • – NY Medicaid Choice lists – same lists are sent to clients with 60-day Choice letters.  CAUTION — Look only at the Long Term Care plans –  (“Health Plans” are Mainstream managed care plans, which are NOT for Dual Eligibles) 

  • See more enrollment numbers – for various NYS plans that provide Medicare and Medicaid services for dual eligibles,  including Medicare Advantage plans – here.
  • Month to Month enrollment growth in MLTC and PACE from 2013 to July 2013 is at Page 5 at this link.

Phased In Roll-Out SCHEDULE — Who must enroll in MLTC? And when?

WHO MUST ENROLL — Medicaid recipients who live in NYC and certain counties (see below) and who:

  • Are dually eligible – they have Medicare AND Medicaid, AND
  • Are age 21 or older, AND
  • Need community-based long-term care for more than 120 days — Who are receiving or are applying for CERTAIN SPECIFIED Medicaid home care and other community-based long term care services.  “Long-term” means you need home care or other long-term care services for more than 120 days.  

See links to press coverage in this article under APRIL 2013 News

  • If you ONLY Need “Housekeeping” services, also known as Level I Personal Care services, as described in 18 NYCRR 505.14(a), you are NOT eligible for MLTC and may still apply to your local DSS Medicaid program for these services. On August 12,  2013, the State directed MLTC plans to disenroll these individuals and transition them back to DSS.  See MLTC Policy 13.21: Process Issues Involving the Definition of Community Based Long Term Care

    • See NYC HRA MICSA Bulletin — Disenrolled Housekeeping Case Consumers (MLTC) 8-13-13.pdf

  • Live in NYC or one of the counties where mandatory enrollment has begun.   (Nassau, Suffolk, Westchester in Jan. 2013)(Orange Rockland began in September 2013)
  • Is not “exempt” or “excluded” from enrolling in an MLTC plan.  See below. 

Phase I (began Sept. 2012):


WHO:  Dual eligibles age 21+ who need certain community-based long-term care services 120 days


Sept. 2012 — Those newly applying for Medicaid personal care (home attendant and housekeeping) must enroll in these plans, and no longer apply at the CASA offices.  

  • Those already receiving Medicaid personal care (home attendant and housekeeping) services begin receiving “Announcement” and then  “60-day letters” from New York Medicaid Choice, giving them 60 days to select a plan.  See enrollment information below.        

Nov. 2012 – Adults newly applying for Consumer Directed Personal Assistance Program (CDPAP) services in New York City must enroll in MLTC plans; those already receiving CDPAP services begin receiving 60-day letters to select a plan in 60 days. 

Jan. 2013 – Adults in NYC receiving medical model Adult Day Care, long-term Certified Home Health Agency (CHHA) services ( 120 days), and Private Duty Nursing Services begin receving 60-day enrollment letters to select an MLTC plan in 60 days.  See enrollment information below.

May 2013 – Long Term Home Health Care Waiver Program (LTHHCP) or (“Lombardi”) recipients –   CMS approval April 1, 2013 to require enrollment into MLTC plans. See HRA Alert. and DOH Directive Approved Long Term Home Health Care Program (LTHHCP) 1915 (c) Medicaid Waiver Amendment

August 2013 – THose individuals needing solely housekeeping services (Personal Care Level I), who were initially required to join MLTC plans, are no longer eligible for MLTC.  New applicants may again apply at the local DSS and those already receiving MLTC are transitioned back to DSS. See MLTC Poliucy 13.21

Phase II (January 2013):

WHERE:     Nassau, Suffolk, and Westchester counties  

WHO:         Dual eligibles age 21+ who need certain community-based long-term care services 120 days newly applying for certain community-based Medicaid long-term care services.

WHICH SERVICES:   Medicaid personal care, CDPAPMedicaid adult day care, long-term certified home health agency (CHHA), or private duty nursing services, and starting in May 2013, Long Term Home Health Care Waiver Program (LTHHCP) or (“Lombardi”) participants,  must enroll in these plans.   Those already receiving these services begin receiving “Announcement” and then “60-day letters” from New York Medicaid Choice, giving them 60 days to select a plan.  See enrollment information below.

See Approved Long Term Home Health Care Program (LTHHCP) 1915 (c) Medicaid Waiver Amendment

Also  in Jan. 2013, for New York City — mandatory enrollment expands beyond personal care to adult dual eligibles receiving  medical model adult day care, private duty nursing, or certified home health agency (CHHA) services for more than 120 days, and in May 2013, to Lombardi program..   These individuals begin receiving “announcement” and then 60-day enrollment notices.. described below.

Phase III (September 2013) (Postponed from June 2013): Rockland and Orange counties  – “front door” closed at local DSS offices Sept. 23, 2013 – after that Medicaid recipients must enroll directly with MLTC plan to obtain home care.

Phase IV (December 2013): Albany, Erie, Onondaga and Monroe counties  –  See below explaining timeline for receiving letters and getting 60-days to enroll.   

Phase V (2014)    Roll-out schedule for mandatory MLTC enrollment in upstate counties during 2014, subject to approval by CMS.  , Source:   NYS DOH  Updated 2014-2015 MLTC Transition Timeline (PDF, 88KB)  (MRT e-mails)  NYS DOH Policy PLanning Updates January 2015 and February 2015

FINAL PHASE (No date set) – People in Assisted Living Program, Nursing Homes, TBI and Nursing Home Transition and Diversion Waiver Programs will all be required to enroll.   

See this statewide list to see what plans are offered in your county.  See more lists of plans here.

In NYC and Counties Where MLTC is Mandatory, WHO DOES NOT HAVE TO ENROLL IN MLTC?  (Exemptions Exclusions)


Download New York Medicaid Choice MLTC Exclusion Form must be signed by physician

  • Individuals in Certain Waiver Programs. These include: Nursing Home Transition Diversion (NHTD) waiver, Traumatic  Brain Injury (TBI)  waiver, Office for People with Developmental Disabilities waiver, and individuals with complex mental health needs receiving services through ICF and HCBS waiver. (Note NHTW and TBI waivers will be merged into MLTC in January 2018).

  • Nursing Home residents WERE excluded from enrolling in MLTC plans or mainstream Medicaid managed care plans but MAY enroll as of Oct. 1, 2015.  New permanent residents MUST enroll. SEE this article. 

  • Medicaid Assisted Living Program residents;

  • Persons receiving hospice services (they may not enroll in an MLTC plan, but someone already in an MLTC plan who comes to need hospice services may enroll in hospice without having to disenroll from the MLTC plan.  See NYS DOH MLTC Policy 13.18: MLTC Guidance on Hospice Coverage (June 25, 2013)  Those who are in hospice and need supplemental home care may still apply to CASA/DSS for personal care services to supplement hospice;

  • Residents of Intermediate Care Facilities for the Developmentally Disabled (ICF/DD), Alcohol Substance Abuse Long Term Care Residential Program, adult Foster Care Home, or psychiatric facilities.

  • People who receive or need ONLY “Housekeeping” services (“Personal Care Level I” services under 18 NYCRR 505.14).  Under state law, these services are limited to 8 hours per week.   If someone does not need assistance with Activities of Daily Living – personal care such as bathing, grooming, walking but only with household chores, they access these services through their Local Medicaid Program (in NYC apply to the Home Care Service Program with an M11q. See —

  • Children under age 18

  • NOTE – the recently obtained (2/2013) New York Medicaid Choice MLTC Exclusion Form excludes an individual certified by physician to have a developmental disability.

SOURCE:  CMS Special Terms Conditions, Amended Sept. 2012), at p. 14 -15

Download New York Medicaid Choice MLTC Exclusion Form – must be signed by physician


  • Native Americans;

  • Dual eligible individuals age 18- 21 who require home care or other long-term care services, and require a “nursing   home level of care,” meaning they could be admitted to a nursing home based on their medical and functional condition;

  • Adults over age 21 who have Medicaid but not Medicare (If they require a “nursing home level of care”) — If they are not yet enrolled in a mainstream Medicaid managed care plan  they may opt to enroll in an MLTC plan    if they would be functionally eligible for nursing home care.  If they enroll in an MLTC, they would receive other Medicaid services that are not covered by the MLTC plan on a fee-for-service basis, not through managed care (such as hospital care, primary medical care, prescriptions, etc.).  However, if they are already enrolled in a mainstream Medicaid managed care plan, they must access personal care, consumer-directed personal assistance, or private duty nursing from the plan.  They may only switch to MLTC if they need adult day care, social environmental supports, or home delivered meals – services not covered by Medicaid managed care plans.   See MLTC Policy 14.01: Transfers from Medicaid Managed Care to Managed Long Term Care

  • Working Medicaid recipients under age 65 in the Medicaid Buy-In for Working People with Disabilities (MBI-WPD) program (If they require a “nursing home level of care”).

  • SOURCE:  CMS Special Terms Conditions, Amended Jan. 2014, at p. 14


Under  MLTC Policy 14.06: Implementation of the Conflict-Free Evaluation and Enrollment Center (CFEEC)    anyone approved for Medicaid  who is seeking Managed Long Term Care will need to first contact NEW YORK MEDICAID CHOICE and request a CFEEC assessment.  If that assessment finds the person eligible for MLTC, then the person can enroll in an MLTC plan.  To schedule an evaluation, call 855-222-8350.


NYLAG’s Guide and Explanation on the CFEEC and MLTC Evaluation Process

This is being implemented pursuant to #28 of the Special Terms and Conditions, which is CMS’s approval of the State’s 1115 waiver to implement mandatory MLTC, DOH has established a conflict-free assessment system for all voluntary enrollments into MLTC, MAP and PACE effective October 1, 2014.

Before, private MLTC plans were responsible for determining eligibility for Medicaid-covered long-term services and supports (LTSS).  This creates an intrinsic conflict of interest, because plans have a financial stake in avoiding high-cost members and attracting low-cost members.  The CFEEC reduces this conflict by having  New York Medicaid Choice (aka Maximus), rather than the MLTC plans, determine eligibility for MLTC.

The  Conflict-Free Evaluation and Enrollment Center (CFEEC)s schedule and conduct initial assessment visits in the home or facility by a nurse (employed by or under contract with the CFEEC).  Using the Uniform Assessment Tool, the CFEEC makes the determination of eligibility for Medicaid LTSS.  If the CFEEC determines that the applicant is ineligible for Medicaid LTSS, it will send a written notice with appeal rights.  If the CFEEC approves the applicant, then any MLTC, MAP, PACE or FIDA plan must accept the applicant’s enrollment.  If the plan disagrees with the CFEEC’s determination of eligibility, it may pursue a dispute adjudication procedure via Maximus and DOH.

The CFEEC was rolled out in phases beginning in NYC in October 2014, and became statewide by May 2015.

  • Will this delay enrollment into MLTC?  Probably.  MLTC plans may not accept an enrollment without confirmation from CFEEC that you are MLTC-eligible.  That confirmation is valid for 60  days.   The State FAQ (Q13) says the CFEEC assessment can be done while Medicaid application is pending, but since a Medicaid application can take more than 60 days – it can be risky.  It is also unclear whether the consumer must only sign an MLTC plan enrollment form within 60 days of the CFEEC assessment, or must actually be enrolled in the plan by that date – the difference can be significant.

See new documents available from NYS DOH on the Conflict-Free Evaluation and Enrollment Center (CFEEC):

WHICH SERVICES ARE PROVIDED BY THE MLTC PLANS – Benefit Package of “Partially Capitated” Plans

MLTC plans must provide the services in the MLTC Benefit Package listed below.  Once you are enrolled in a MLTC plan, you may no longer use your Medicaid card for any of these services, and you must use providers in the MLTC plan’s network for all of these services, including your dentist.  The providers will be paid by the MLTC plan, rather than billing Medicaid directly.

MLTC Benefit Package (Partial Capitation) (Plan must cover these services, if deemed medically necessary.  Member must use providers within the plan’s provider network for these services).  

  • Home Care, including:
  • Adult Day Health Care (medical model and social adult day care)
  • Personal Emergency Response System (PERS),
  • Nutrition — Home-delivered meals or congregate meals
  • Home modifications
  • Medical equipment such as wheelchairs, medical supplies such as incontinent pads, prostheses, orthotics, respiratory therapy
  • Physical, speech, and occupational therapy outside the home
  • Hearing Aids and Eyeglasses
  • Four Medical Specialties:
    • Podiatry
    • Audiology + hearing aides and batteries
    • Dental
    • Optometry   + eyeglasses
  • Non-emergency medical transportation to doctor offices, clinics (ambulette)
  • Nursing home care

SOURCE: NYS DOH Model Contract for MLTC Plans (See Appendix G),    CMS Special Terms Conditions, Amended Sept. 2012), at p. 57, Attachment B

NOTE WHICH SERVICES ARE NOT COVERED BY MLTC PARTIALLY CAPITATED PLANS — but are covered by “fully capitated”  Medicaid Advantage Plus or PACE plans

  • Primary and acute medical care, including all doctors other than the Four Medical Specialties listed above, all hospital inpatient and outpatient care, outpatient clinics, emergency room care, mental health care
  • Lab and radiology tests
  • Prescription drugs
  • Assisted living program
  • Hospice services – MLTC plans do not provide hospice services but as of June 24, 2013, an MLTC member may enroll in a hospice and continue to receive MLTC services separately.  Before s/he had to disenroll from the MLTC plan.  PACE plans may not give hospice services.  See NYS DOH MLTC Policy 13.18: MLTC Guidance on Hospice Coverage (June 25, 2013) 

HOW DO PEOPLE IN MLTC Partial Capitation Plans Receive services not covered by the plans? These use –

  • Original Medicare OR Medicare Advantage plan AND
  • Regular Medicaid  

WHAT SERVICES ARE “MEDICALLY NECESSARY?”  The Federal Medicaid statute requires that all managed care plans make services available to the same extent they are available to recipients of fee-for- service Medicaid.  42 U.S.C. § 1396b(m)(1)(A)(i); 42 C.F.R. §§ 438.210(a)(2) and (a) (4)(i).  The  NYS DOH Model Contract for MLTC Plans also includes this clause: “Managed care organizations may not define covered services more restrictively than the Medicaid Program”

You 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.  See PowerPoint explaining Maximus/NY Medicaid Choice’s role in MLTC enrollment (this is written by by Maximus)

  1. “ANNOUNCEMENT ” LETTER  Important Medicaid Notice— This “announcement letter” is sent to people with 120 days left on their authorization period for Medicaid personal care, certified home health agency, private duty nursing, CDPAP, and medical model adult day care, or LOmbardi services, telling them  “MLTC” is coming letter sent in English and Spanish. It does not state that they have to enroll yet.. just says that it is coming and to expect a letter. 

  2. MANDATORY ENROLLMENT PACKET  – Sent by NY Medicaid Choice 30 days after the 1st “announcement” letter – stating recipient has 60 days to select a plan OR will be assigned to an MLTC plan.   The first packets were sent in Manhattan in July 2012, telling them to select a plan by September 2012, later extended to October 2012.  The Packet includes: 

NYC lists –

MLTC Medicaid Plans – New York City

Medicaid Advantage Plus – New York City

Program of All-Inclusive Care for the Elderly (PACE)



CONTINUITY OF CARE — One important factor in choosing a plan is whether you can keep your aide that worked with you when CASA/DSS, a CHHA, or a Lombardi program authorized your care before you enrolled in the MLTC plan.  When MLTC began, the plans  were  required to contract with all of the home care agencies and Lombardi programs that had contracts with the local DSS for personal care/ home attendant  services, and pay them the same rates paid by the local DSS in July 2012.  That requirement ended   March 1, 2014.