Long-Term Nursing Home Placement Notice Provider Memo
Required Documentation for Chronic Care Eligibility
Dear Nursing Home Administrator:
As a valued partner in delivering comprehensive, long-term care to MetroPlusHealth members identified as requiring Long-Term Nursing Home Placement (LTNHP), we want to ensure that the process for obtaining coverage and reimbursement is clear and efficient. Below is an overview of the required documentation, timelines, and key responsibilities.
Required Documentation for Chronic Care Eligibility
To determine chronic care eligibility for nursing home coverage for consumers* who require LTNHP, the New York State Department of Health (“The Department”) requires specific documentation. This includes, but is not limited to:
- DOH-4220 “Access NY” – for consumers without any existing Medicaid coverage
- DOH-5178A “Supplement A”
- LDSS-3559 – Residential Health Care Facility Report of Medicaid Recipient Admission/Discharge/Re-Admission/Change in Status or
MAP-2159i – Notice of Permanent Placement Medicaid Managed Care (NYC). This must be submitted to the plan for approval and signature. - DOH-5147 – Submission of Application on Behalf of Applicant or
MAP-3044A – Facility Submission of Application on Behalf of Consumer (NYC); and - Any documentation or information provided by the consumer needed to determine financial eligibility.
Action Required: MetroPlusHealth participating facilities assisting New York City residents with applying for long-term nursing home benefits should fax all required documentation to the Department at (518) 408-9792. Facilities should separate faxes by consumer.
For your convenience, we have prepared a detailed tip sheet outlining the long-term placement process, including steps your facility must take and timelines for submission to the Local Department of Social Services (LDSS)/Human Resources Administration (HRA) and the Department.
Timeline and Coverage Authorization
MetroPlusHealth will work closely with your facility to ensure timely submission of all paperwork. Please note:
- Plan approval is required before coverage for permanent placement can be authorized.
- Subsequently, billing by your facility for the approved timeframe cannot occur until the Department assigns the N code for LTNHP, confirming eligibility per previous Department communication.
Members Transitioning back to the community
If a member transitions from the Nursing Home back into the community, please submit the MAP-259f, which must be completed by your facility; please also do the following:
- Fax form to: (212) 908-3023
- Mail form to:
Medical Assistance Program
Nursing Home Eligibility Division (NHED)
P.O. Box 24210
Brooklyn, New York 11202-9810
Your diligence in this process is greatly appreciated. Please prioritize this in your daily processes and reach out to our MetroPlusHealth Managed Long-Term Care Department at (855) 355-5282 if you have any questions or need assistance.
Thank you for your continued commitment to high quality care for our MetroPlusHealth members and your residents.