ABCs of Managed Long-Term Care—A Glossary

Activities of Daily Living

Activities necessary for basic self-care such as getting dressed, eating, bathing, and using the bathroom. Managed long-term care (MLTC) pays for people to receive the necessary help with activities of daily living. The support is provided by a home health aide (HHA) or personal care aide (PCA).

Adult Day Health Care

A place people can go to during the day to receive assistance with their activities of daily living and socialize. It is usually located within a senior center or nursing home. People who attend may also receive the following services: nursing support; primary care physician; physical, speech, and occupational therapy; nutritional counseling; dentistry; podiatry; and medication administration. Adult day health care is a covered MLTC service.

Advanced Directives

A collection of wishes of how an individual wants to be cared for at the end of their life. A health care proxy and living will are two types of documents where advanced directives are usually described.

Audiology

A covered MLTC service that includes hearing exams; hearing aid evaluation; selecting, fitting, and dispensing of hearing aid; hearing aid repair; replacement of batteries when necessary.

Care Coordination

A core service for an MLTC plan. It is commonly provided by a care manager, working on an interdisciplinary team (i.e. nurse, social worker, physical or occupational therapist and support staff). Care coordination is the act of the team working with the individual to create a care plan that identifies their social, medical, and functional needs. It also includes the coordination of all services in the care plan—including community-based services and physician services—and monitoring the care plan to make sure it always meets the individual’s needs.

Care Manager

A licensed professional, usually a social worker or nurse, who provides care management. A care manager works with the individual to create a care plan that identifies their social, medical, and functional needs. The care manager will also coordinate the services in the care plan and monitor the care plan to make sure it always meets the individual’s needs.

Care Plan

A written plan created by the member and the care manager that identifies the necessary services and support to meet an individual’s medical, social, and functional needs.

Certified Home Health Agency (CHHA)

An agency that provides nursing, rehabilitative, and other skilled services to people in their homes. CHHAs can be paid by Medicaid, Medicare and other insurance plans.

Consumer Directed Personal Assistance Services (CDPAS)

A home care program for people to receive assistance with their activities of daily living and other home care services from a personal assistant (PA) whom they hire and supervise. CDPAS is an alternative to having PAs supplied by an agency that hires and supervises them.

Covered Service

A service an MLTC must provide or pay for according to their contract with the Department of Health. It can also be referred to as a guaranteed service as it is described on the ICS Community Care website. Covered services need to be necessary according to the judgment of a nurse or care manager. Covered services include: care management, nursing, therapy, nursing home care, medical equipment and supplies, podiatry, dentistry, optometry, respiration therapy, transportation, adult day care, and social day care.

Dental Care

A covered MLTC service that includes the routine, preventive, and restorative care for the teeth such as cleanings, gum scaling, fillings, bridgework, or dentures.

Dual Eligible

People who either: 1) have insurance from both Medicare and Medicaid or 2) meet the criteria to have insurance from both Medicare and Medicaid (See Medicaid Eligible and Medicare Eligible). People receiving services from an MLTC may be eligible for both Medicare and Medicaid, but MUST be Medicaid Eligible.

Durable Medical Equipment (DME)

Devices and equipment needed in the treatment of a specific medical condition. DME may also be used to support functioning in activities of daily living. Includes but is not limited to: mobility devices such as wheelchairs, walkers, canes, and scooters; beds; bathroom equipment; adaptive aids such as reachers; and all repairs. A covered MLTC service.

Guaranteed Service

A covered service. See Covered Service.

Health Care Proxy

A document that assigns a person to make end-of-life decisions when an individual is no longer able to.

Home Attendant

A personal care aide (PCA) who works for a home attendant agency. A home attendant assists an individual with their activities of daily living.

Home Attendant Agency

A home care agency in New York City that has a contract with the New York City Human Resources Administration to provide personal care services to Medicaid beneficiaries.

Home Delivered Meals

Covered MLTC service that provides meals to members according to the plan of care.

Home Health Aide

A PCA with additional training who can provide assistance with the activities of daily living and other skilled services such as assistance with medications and rehabilitation exercises under the supervision of a nurse.

Housekeeper

A paraprofessional who assists with cleaning, laundry, and other housekeeping duties.

Human Resources Administration (HRA)

The agency that serves as the local department of social services for New York City on behalf of New York State. Oversees and administers the rules and regulations for the personal care program and other Medicaid services in New York City.

Licensed Home Care Services Agency (LHCSA)

Provides home care and other supportive services to individuals who need assistance with their activities of daily living. LHCSAs employ HHAs and PCAs. LHCSAs may contract with a managed long-term care plan to provide services.

Living Will

A legal document that describes how an individual wishes to be cared for at the end of their life. It includes the types and amounts of treatments, medications, food, water and other types of services.

Local Department of Social Services

Oversees the Medicaid program for a certain area. In New York City, it is called the Human Resources Administration.

Long-Term Home Health Care Program (LTHHCP)

Also known as “Nursing Homes Without Walls.” LTHHCPs offer a full range of long-term care services and support in the home to people with a physical or mental condition a nursing home usually provides.

Managed Long-Term Care (MLTC)

MLTCs provide coordinated health and long-term care services in the home to adults who are Medicaid eligible and who have a chronic illness or disability that requires at least 120 days of home care. The services include, but are not limited to: care management, PCA or HHA services, nursing, rehabilitation services, medical equipment and supplies, podiatry, dentistry, optometry, respiration, transportation, adult day care and social day care. MLTCs do not pay for physician services, hospitalizations, or medications, but will coordinate those services. Compared to the Personal Care Program, and traditional Medicaid and Medicare, MLTC services are more coordinated and more customized, and out-of-pocket expenses are usually lower. MLTCs provide their services through a contract with the New York State Department of Health and are overseen by the Local Department of Social Services (in New York City, the Human Resources Administration).

Mandatory Enrollment

All recipients of Medicaid home care and other long-term care services are required to enroll in an MLTC plan. Individuals who do not select a plan will be automatically enrolled in one of New York City’s 13 MLTC plans.

Medicaid

A New York State insurance program for people with a disability who receive SSI, or those who have an income at or below a certain level. Most services are covered, including medical services, hospitalizations, and medications. Insurance coverage can be under a traditional fee-for service plan to providers or under a managed care plan (see: Medicaid Managed Care). For people with chronic conditions, Medicaid also pays for long-term care services like nursing homes, personal care, long-term home health care, or managed long-term care.

Medicaid Beneficiary

A person who has Medicaid as their insurance. May be a person who also has Medicare.

Medicaid Eligible

Meeting the financial criteria to participate in the Medicaid program. People with an MLTC must be Medicaid eligible. May involve the need for a spend down or managing surplus income or excess income (See: Surplus Income)

Medicaid Managed Care Plan

Broad state insurance program for people receiving SSI, or those who have an income at or below a certain level. Usually best suited for a person who does not need long-term care. People cannot be enrolled in both a Medicaid managed care plan and a managed long-term care plan.

Medical Supplies

A covered MLTC service that includes items used in the treatment of a specific medical condition such as: diabetic supplies, dressing and other wound care supplies, urinary catheters, incontinence supplies, and nutritional supplements.

Medicare and Part A, Part B, Part D

Comprehensive federal insurance program for people >65 years old or with a disability. Coverage can be under a traditional fee-for-service plan to providers or under a managed care plan called a

Medicare Advantage Plan

Part A

covers hospitalizations and skilled nursing facilities.

Part B

covers professional services like physicians, physical therapy, or dentistry.

Part D

covers medications.

Medicare Eligible

Individuals who are >65 years old or have a disability that meets the criteria to receive health insurance through Medicare. People receiving services from an MLTC may be eligible for both Medicare and Medicaid, but MUST be Medicaid eligible.

Non-Covered Service

A service an MLTC is not obligated to provide but coordinates such as physician services, hospitalizations, prescribed and non-prescribed medications, laboratory services, radiology services, emergency transportation, and mental health services.

Nutrition

An MLTC-covered service. It includes an assessment by a qualified nutritionist of the dietary needs of an individual.

Optometry

An MLTC-covered service that include eye exams, eyeglasses, and contact lenses.

Out-of-Network Provider

A provider not under contract with an MLTC. An out-of-network provider may provide services to an individual with an MLTC in specific situations, usually for new members so that services are not stopped, disrupted, or suspended.

Paraprofessional Service

A covered MLTC service that includes the services of home health aides, personal care aides, and housekeepers to assist individuals with their activities of daily living and allow them to live independently in their home.

Personal Assistant

A paraprofessional who provides assistance with activities of daily living and other home care services who is employed by and supervised by the person receiving services. (See also: CDPAS)

Personal Care Aide (PCA)

Paraprofessional employed by an LHCSA who can provide assistance with the activities of daily living and light housekeeping.

Personal Emergency Response System (PERS)

A covered MLTC service. PERS is an electronic device on a necklace or bracelet to get help in the event of an emergency.

Podiatry

A covered MLTC service that includes routine foot care such as treatment of corns and calluses, nail trimming and non-routine care such as incisions, excisions, repair of tendons, and treatment of dislocations.

Provider Network

A collection of providers under contract with an MLTC that offer a covered service. People enrolled with an MLTC are limited to using the provider network except in specific situations (usually for new members), to make sure services are not stopped, disrupted, or suspended.

Rehabilitation Services (Physical, Occupational and Speech Therapy)

A covered MLTC service that includes physical, occupational, and speech therapy evaluations, diagnosis, and treatments

Respiratory Services

An MLTC-covered service that includes procedures and techniques that rehabilitate and maintain an individual’s ability to breathe.

Skilled Nursing Facility

An MLTC-covered service also known as a nursing home. A nursing home is a place that provides 24 hours of nursing, medical, and rehabilitation services to people who need help after a hospitalization or who can no longer live independently because of a chronic physical or mental condition.

Skilled Services

A covered MLTC service that includes home care services provided by a physical therapist, occupational therapist, speech therapist, registered nurse, licensed practical nurse or home health aide. Skilled services help people stay in their home and include, but aren’t limited to: medication management, glucose monitoring, physical therapy, home infusions or nebulizer treatments.

Supplemental Security Income (SSI)

A program that helps senior adults and people who are blind or have another disability with little or no income. It provides cash to meet basic needs for food, clothing, and shelter.

Social and Environmental Supports

A covered MLTC service that supports the medical needs of an individual that includes, but is not limited to: home improvements and modifications, appliances and assistive devices, and independent living skills training.

Social Adult Day Care

A place people can go to during the day to socialize and participate in other recreational and therapeutic activities. It is usually located within a senior center or nursing home. Social Day Care is a covered MLTC service, and unlike an Adult Day Program, does not offer skilled services.

Surplus Income

Also called “Excess Income” or “Spend Down.” If an individual’s monthly income is more than Medicaid allows, the amount the income is greater is called excess income, or the amount an individual must “spend down.” A MLTC will work with individuals to manage the surplus and ensure they will continue to be Medicaid eligible.

Transportation

A covered MLTC service that includes public buses or trains, Access-A-Ride, car service, ambulette, or ambulance to transport someone to a medical appointment, or an adult or social day care program that is part of an individual’s care plan.

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