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Dual Medicare-Medicaid Programs Patient Info 2014

(provided as an educational tool only for IPA member physicians to explain to patients)


In 2013 NY State required about half of Medicare-Medicaid Dual Eligible patients to join MLTC (Managed Long Term Care) agencies which have responsibility for those services provided by the patient’s Medicaid card, consolidating the services of multiple prior agencies (NYS partial capitation).  In ‘2014 these same patients will then be switched to a new system called ‘FIDA or Fully Integrated Duals Advantage’ plans which will cover the remaining services provided both by their Medicare as well as Medicaid cards (NYS full capitation). Firstly, those patients who use home attendant services, visiting home nurse services, recurrent physical therapy, mental health therapy, have chronic ill conditions and/or disability/difficulty with instrumental or basic activities of daily living - will be converted.


Frequently Asked Questions:  


  1. What types of plans or agencies may Medicare-Medicaid patients be registered with?

  • (1) Insurance plan (in most cases Medicare and Medicaid cards; or elect to join a PACE (Program of All-inclusive Care for the Elderly) plan or MAP (Medicare Advantage Plan)
  • (2) Prescription Drug Plan (from 30 available PDP plans, each having a variety of medication formularies) or have an integrated prescription plan as part of PACE or MAP. 
  • (3) Managed Long Term Care agency (25 MLTC agencies available in NYC),
  • (4) Personal Care Worker agency (> 400 agencies or LHCSA’s available in Queens & Brooklyn) which supply the PCW or home attendant (if approved by Medicaid)

(Note: PACE and FIDA are a consolidation of Insurance plan, Prescription drug plan and MLTC)


  1. What services do MLTC agencies (also known as partially capitated state plans) now provide?

Home Care including:

  • Certified Home Health Agency (CHHA) services (Visiting Nurse, Private Duty nurse, In-home visiting Physical or Occupational Therapist, Home Health Aide)
  • Personal Care (Housekeeping, Home attendant, Consumer Directed Personal Assistance)
  • Nutrition services - Home-delivered meals or congregate meals


Home Modification including:

  • Durable Medical Equipment (DME) such as hospital beds, wheelchairs, respiratory nebulizers; prostheses & orthotics; Medical Supplies such as incontinent pads, etc.


Ancillary Healthcare Specialties & Ancillary Facilities including:  

  • Ancillary Specialties: Podiatry, Physical-Occupational-Speech Therapy (outside of home),  Optometry (eyeglasses), Dentistry, Audiology (hearing aid, batteries),.
  • Ancillary Facilities (e.g. Adult Day Care)


  Healthcare Transportation to doctor’s offices or clinics via livery or ambulettes (non-emergency)


  1. Which additional services now covered by Medicare are provided by fully capitated state plans such as PACE or Medicaid Advantage Plus and soon by FIDA (within that plan’s network providers)?

  • Primary or acute Medical Care from doctors (other than Ancillary Specialties), hospital Inpatient care, Outpatient care, Emergency room care, Mental health care, Assisted Living care
  • Lab tests and Radiology tests
  • Prescription drugs


  1. Can you lose your home attendant if you switch between MLTC agencies?  

There is a mechanism that allows patients to switch and choose different MLTC’s without necessarily losing their favorite personal care worker.  As of Feb. 2013 all NYC, Nassau, Suffolk, and Westchester MLTC plans are required to contract with all home attendant, housekeeping and personal care worker vendors by December 2013.  See the legal documents: ‘MLTC Policy 13.04: Personal Care Contracting’ and ‘Policy for Transition of Consumer Directed Personal Assistance Services into Managed Care’. If patients learn that the assigned MLTC plan does not contract with their current home attendant vendor, they should cite the above policy and ask the MLTC plan to do so.  If the MLTC plan refuses to allow the client to keep that aide, call the State Dept. of Health at 1-866-712-7197 (MLTC Complaint Line).


  1. What criteria are useful to choose an MLTC agency and future FIDA plan?

Twenty-six MLTC agencies now have associated insurance plans and FIDA plans, but not all of them have large experience or high performance ratings.  You can join a fully integrated plan such as PACE program before the mandatory enrollment in ‘2014 or join a company that runs both an MLTC agency and insurance plan or wait, but you must choose an MLTC or switch to a preferred MLTC now if you have already been using long-term care services.  If not satisfied, you can change MLTC agencies every month in ‘2013 (in ‘2014 you can change every 6 months).

You can use the following criteria to choose an appropriate MLTC agency: the agency-plans with the most experience with this new type of integrated healthcare service, the largest or financially healthiest agency-plans, and the agency-plans with better performance ratings.  New York State provides a scorecard ‘2013 and ‘2014 analysis of MLTC plans (including all contact telephone info).                         



New York State Online References:

  1. http://www.health.ny.gov/health_care/managed_care/mltc/consumer_guides/nyc/
  2. http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
  3. http://www.health.ny.gov/health_care/managed_care/mltc/mltcplans.htm
  4. http://wnylc.com/health/entry/114/  (website has information similar to this handout).




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