Legislative Update: “The Lock-In” for Long Term Care

As in previous years, much of New York State’s 2018-2019 enacted budget focuses on healthcare spending. This year enacts several important updates, but you should understand in particular the new “lock-in” provision for people enrolled in managed long-term care (MLTC) plans.

No “lock-in” previously existed—New Yorkers who enrolled in managed long-term care plans could change their plans at any time. Recent amendments to the law now limit a consumer’s ability to change plans. Effective October 1, 2018, the new law provides that:

Enrolled individuals can switch plans for any reason and at any time within 90 days of either (i) notification of enrollment or (ii) the effective date of enrollment, whichever is later.

After the first 90 days, the Department of Health may prohibit an individual from switching plans more than once every 12 months unless the individual can demonstrate “good cause.”

The “good cause” requirement would allow individuals to switch plans within the 12-month period if they can demonstrate one of the following: (i) Poor quality of care under the current plan; (ii) Lack of access to providers experienced in caring for the individual’s needs; or (iii) Lack of access to covered services. The statute also gives the Commissioner of the Department of Health the authority “otherwise determine” that an individual has demonstrated “good cause” that merits switching plans.

In short, individuals on MLTC plans are “locked into” their plans after the first 90 days for the next 12 months. People who need to change plans after the 90-day period cannot do so unless they have valid, demonstrable reasons for changing plans.

The amendment is obviously an attempt to control healthcare spending, but New Yorkers face potentially significant impacts. You have only three months to evaluate your current plan and determine whether it is right for you. After that, the the Department of Health will need to approve the change. This could prove time-consuming and difficult, particularly if you aren’t receiving the care you need.

The bottom line is this: if you are considering changing plans or providers, the law will severely limit your ability to make that change after October 1.

Contact a New York Elder Law Attorney

If you’re feeling overwhelmed or just have questions about how the new law could affect you, the lawyers at Goldfarb Abrandt & Salzman LLP can help. Our firm has helped people understand their healthcare rights for more than 25 years. Call us at (212) 387-8400 or send us an email to speak with one of our New York healthcare attorneys today.