New York Managed Long Term Care (MLTC): The Complete 2026 Guide

In New York, most Medicaid long-term care at home or in the community is delivered through a managed plan called Managed Long Term Care (MLTC). These capitated plans cover personal care, CDPAP, home health aide visits, adult day care, and short-stay nursing facility coverage. This guide covers the four product types (MLTCP, MAP, PACE, and discontinued FIDA), the 2026 plan landscape, the September 1, 2025 Minimum Needs Requirement, the 9-month lock-in under MLTC Policy 21.04, the NYIAP three-stage assessment, plan-level utilization management, the CMS January 1, 2026 prior-authorization rule, the long-stay nursing-home rule, fair-hearing rights with Aid Continuing, the Engesser settlement's indirect effects, and the three structural threats to MLTC's future (S2332-A, OBBBA Section 71117, and the March 31, 2027 1115 MRT demonstration expiration).

TL;DR

Managed Long Term Care (MLTC) is New York's program for delivering Medicaid long-term services and supports, personal care, CDPAP, home health aide visits, adult day care, and short-stay nursing facility coverage, through capitated managed care plans. It is authorized by NY Public Health Law § 4403-f, operates federally under New York's 1115 Medicaid Redesign Team (MRT) Demonstration (currently approved through March 31, 2027), and serves approximately 280,000-300,000 New Yorkers with $22 billion in annual public spending in 2026.

Eight things to know going into 2026:

1. There are three currently-operating MLTC product types: MLTCP (partial capitation, Medicaid only); MAP (Medicaid Advantage Plus, fully integrated dual coverage); and PACE (Program of All-Inclusive Care for the Elderly, the most comprehensive integrated dual product). FIDA was discontinued December 31, 2019; FIDA-IDD remains active separately.

2. MLTC is mandatory for dual-eligibles age 21+ needing community-based long-term services for more than 120 days. Mandatory enrollment now covers all 62 NY counties.

3. The September 1, 2025 Minimum Needs Requirement under MLTC Policy 25.04 and 25 OHIP/ADM-03 raised the eligibility floor for MLTCP and MAP enrollment: limited assistance with 3+ ADLs, OR 2+ ADLs supervisory if a documented Alzheimer's/dementia diagnosis is on file. Pre-September 1, 2025 enrollees retain Legacy Status as long as they remain continuously enrolled. PACE is exempt from the new minimum.

4. 2026 plan count: ~22 MLTCP plans, ~12 MAP plans, 10 PACE plans operating statewide. Plan availability varies by county.

5. Lock-in rule: After a 90-day grace period post-enrollment, members are locked in for 9 months (per MLTC Policy 21.04, the operative policy is 21.04, not the older 21.02 that some sources still cite). Good Cause exceptions permit mid-lock-in switching.

6. Three structural threats loom over MLTC's future: (a) S2332-A / A6346-A (Home Care Savings & Reinvestment Act) would repeal MLTCP entirely effective April 1, 2028 or upon a Commissioner of Health certificate of readiness, note: many sources still cite an outdated April 1, 2026 effective date; (b) OBBBA Section 71117 ratchets the MCO-tax safe harbor from 6% to 3.5% by 2032, threatening MLTC's federal-match capitation funding; (c) the 1115 MRT demonstration expires March 31, 2027 with renewal application due April 1, 2026, as of May 2026, NYSDOH has not yet posted a final renewal package.

7. NHTD and TBI 1915(c) waivers remain CARVED OUT of MLTC in 2026. The administrative carve-IN target has slipped to January 1, 2027 (not enacted in FY 2026 budget). Participants in those waivers receive services FFS, not through MLTC.

8. Effective January 1, 2026, plans must decide standard service authorizations within 7 calendar days (down from 14) per the CMS Interoperability and Prior Authorization Final Rule. Expedited remains 72 hours.

If a single sentence captures MLTC's 2026 status: MLTC is a $22-billion delivery system serving 300,000 New Yorkers under a federal demonstration that expires in 11 months, with a state-level repeal bill pending and federal capitation-funding mechanics under simultaneous attack, but for now, it remains the operating reality for nearly every dual-eligible New Yorker who needs help at home.

1. Statutory and Regulatory Framework

MLTC sits inside a five-layer authority stack: federal statute → federal regulation → 1115 demonstration → state statute → state regulation.

NY Public Health Law § 4403-f is the authorizing statute. Originally enacted in 1997 as a permissive authority for capitated long-term care, § 4403-f was substantially amended by Part H of Chapter 59 of the Laws of 2011 (which authorized mandatory enrollment as part of the Medicaid Redesign Team work) and by Part DD of Chapter 56 of the Laws of 2020 (FY 2020-21 budget; created the New York Independent Assessor Program, the 30-month community Medicaid lookback, and the minimum-needs framework that produced 2025's policy).

Key § 4403-f subsections to know:

• § 4403-f(1), definitions of "managed long term care plan," "comprehensive plan" (MAP and PACE), and "partially capitated managed long term care plan" (MLTCP).
• § 4403-f(3), certificate-of-authority requirements.
• § 4403-f(7), the mandatory-enrollment mandate: dual eligibles 21+ needing 120+ days of community-based long-term care.
• § 4403-f(7)(b), voluntary enrollment populations.
• § 4403-f(7)(f), statutory exclusions (OPWDD-certified residents, ICF/IID residents, primary mental-health diagnoses eligible for HARP, certain immigration statuses).
• § 4403-f(7-a), long-term nursing-home stay (LTNHS): MLTCP plans cover the first 3 months of an LTNHS designation, then disenroll the member to FFS Medicaid.
• § 4403-f(11), minimum-needs authority (the statutory hook for MLTC Policy 25.04).

State regulations at 10 NYCRR Part 98 (Subpart 98-1) provide the operational rulebook: certification, financial solvency, network adequacy, quality programs (QARR for MLTC), and grievance procedures. 18 NYCRR Part 360 governs Medicaid eligibility and procedure, § 360-10 specifically addresses managed-care enrollment and § 360-10.8 is the operative aid-continuing provision. Services delivered through MLTC are governed by 18 NYCRR § 505.14 (Personal Care Services) and 18 NYCRR § 505.28 (CDPAP).

Federal authority. NY MLTC operates federally under the 1115 Medicaid Redesign Team (MRT) Demonstration, identifier 11-W-00114/2 on the CMS demonstration list. The current renewal period was approved March 23, 2022 and runs through March 31, 2027. CMS approved a major amendment in 2024 (NYHER, the New York Health Equity Reform amendment) to fund Health Equity Regional Organizations (HEROs) and Social Care Networks. The renewal application for the post-March-31-2027 period was due April 1, 2026; as of May 2026, NYSDOH has not yet posted a final renewal package, only amendments and tribal-consultation drafts. The federal substrate sits at 42 USC § 1396u-2 (Medicaid managed care principles), 42 CFR Part 438 (Medicaid managed-care regulations including § 438.4 actuarial soundness, § 438.210 service authorization, and § 438.402 grievance and appeal authority).

For consumers reading this article in 2026: MLTC's existence at the federal level depends on the 1115 demonstration's renewal. While CMS has historically renewed NY's MRT demonstration on schedule, the OBBBA-era federal climate creates real uncertainty about renewal terms.

2. The Four MLTC Product Types

NY's MLTC program statutorily includes three currently-operating product types (MLTCP, MAP, PACE) and one discontinued product (FIDA).

MLTCP, Partial Capitation MLTC

The most common product. Covers Medicaid-only long-term services and supports, personal care, CDPAP, home health aide, adult day health care, Assisted Living Program (ALP), short-stay NF, DME, NEMT, optometry/podiatry/audiology, some dental and PT/OT/ST. Does NOT cover Medicare benefits, inpatient hospital, retail pharmacy (effectively carved out for most members), or behavioral health. Premium: $0 to the member if Medicaid-only; if Medicaid-with-spend-down, the spend-down (sometimes met via a pooled-income trust) flows through. ~22 plans operating statewide in 2026 with ~250,000-270,000 members.

MAP, Medicaid Advantage Plus

A "Fully Integrated D-SNP" (FIDE-SNP) under CMS terminology. Covers both Medicare AND Medicaid in a single plan: Medicare Parts A, B, D plus all Medicaid services including long-term care. The most fully-integrated dual coverage available in NY in 2026 outside of PACE. Premium: $0 to the member because Medicaid pays the Medicare premium cost-share for full-benefit duals. Networks are smaller than MLTCP (because the plan must contract with both Medicare and Medicaid providers). ~12 plans operating in 2026 with ~25,000-30,000 members. The FIDA-style integrated appeals process for MAP is being phased out December 31, 2025 and replaced with parallel Medicare and Medicaid appeal tracks. (Brevy's separate /medicaid/new-york/medicaid-advantage-plus article covers MAP in depth.)

PACE, Program of All-Inclusive Care for the Elderly

The most comprehensive integrated dual product. Federal authority is permanent (Sections 1894 and 1934 of the Social Security Act / 42 USC §§ 1395eee, 1396u-4), not 1115-dependent, which means PACE is the most insulated MLTC product from federal demonstration politics. Covers Medicare AND Medicaid AND additional in-house services through PACE day centers (integrated primary care, on-site pharmacy, transportation, social activities). Eligibility: age 55+ (NOT 21+ like MLTCP/MAP); dual or Medicaid-only; certified as needing nursing-home level of care; able to live safely in the community at the time of enrollment; reside in a PACE plan's service area. Not subject to the September 1, 2025 Minimum Needs Requirement, PACE eligibility uses NF-level-of-care, not the new ADL threshold. 10 plans operating in 2026 with approximately 10,500 enrollees. The largest is CenterLight Healthcare PACE in the Bronx (~6,881 enrollees); the newest is PACE at Hudson Headwaters in Glens Falls, opened February 1, 2025.

FIDA, Discontinued

The FIDA demonstration for community duals ended December 31, 2019 and has not been revived. Members were transitioned to MAP or MLTCP. FIDA-IDD, a separate demonstration for individuals with intellectual and developmental disabilities, remains active under a separate CMS Financial Alignment demonstration.

Side-by-side comparison

3. The 2026 MLTC Plan Landscape

The most reliable directories are the NYSDOH Managed Long-Term Care Plan Directory at health.ny.gov/health_care/managed_care/mltc/mltcplans.htm and NY Medicaid Choice's by-county marketing materials at nymedicaidchoice.com/choose/plans-by-county/. Plan rosters change as plans consolidate, exit, or enter, verify against the live directory before any enrollment decision.

Partial capitation plans (MLTCP) operating in 2026 include (approximately 22 plans):

• VNS Health MLTC (formerly VNS Choice; the dominant statewide nonprofit; absorbed Prime Health Choice in 2025).
• Centers Plan for Healthy Living (Centers Health Care; statewide).
• Healthfirst Senior Health Partners (NYC hospital-sponsored nonprofit; NYC + LI focus).
• Fidelis Care at Home (Centene Corp.; statewide).
• Senior Whole Health of New York (Molina Healthcare).
• AgeWell New York (nonprofit; Hudson Valley + downstate).
• Aetna Better Health (MLTC) (CVS Health/Aetna; NYC + LI).
• Elderplan / HomeFirst (MJHS Health System nonprofit).
• MetroPlus MLTC (NYC Health + Hospitals public benefit).
• EmblemHealth MLTC (mutual; downstate).
• iCircle Care MLTC (CDS Wolf Foundation / Heritage Christian; western/central NY).
• Independent Living Systems (ILS) NY.
• RiverSpring at Home (RiverSpring Health nonprofit).
• VillageCareMAX (VillageCare nonprofit).
• Hamaspik Choice (nonprofit; downstate).
• Anthem HealthPlus MLTC (Anthem/Elevance).
• ArchCare Community Life (Archdiocese of NY; NYC + Westchester).
• MVP Health Care MLTC (Capital region).
• Integra MLTC (Integra Managed Care).
• Kalos Health MLTC (western NY).
• Senior Network Health (Excellus BlueCross BlueShield; central NY).
• Empire BlueCross BlueShield MediBlue HealthPlus MLTC.

MAP plans (approximately 12 in 2026) include Healthfirst CompleteCare, VNS Health Total, Centers Plan for Medicaid Advantage Plus, Anthem HealthPlus Full Dual Advantage LTSS, Hamaspik Medicare Choice MAP, RiverSpring MAP, Senior Whole Health of New York MAP, VillageCareMAX MAP, Elderplan FIDE-SNP MAP, MetroPlusHealth UltraCare, Empire MediBlue HealthPlus Duals Plus, AgeWell New York MAP.

PACE plans (10 in 2026): CenterLight Healthcare PACE (Bronx, ~6,881); ArchCare Senior Life (Manhattan + Harlem center opened 2025, ~913); ElderONE (Rochester, ~822); PACE CNY (North Syracuse, ~609); Eddy SeniorCare (Schenectady, ~455); Fallon Health Weinberg-PACE (Amherst/Buffalo, ~258); Catholic Health LIFE (Buffalo, ~248); Complete SeniorCare (Niagara Falls, ~151); Total Senior Care (Olean, ~126); PACE at Hudson Headwaters (Glens Falls, ~42, newest, opened Feb 1 2025).

Recent plan exits and entries (2024-2026):

• ICS (Independence Care System) MLTC exited 2019 with member transfers.
• Prime Health Choice MLTCP was acquired by VNS Health in 2025 (§ 4403-f(11)(b) post-acquisition reporting filed).
• PACE at Hudson Headwaters opened February 1, 2025.
• ArchCare Senior Life Harlem PACE Center opened 2025.
• No plan closures announced for the 2026 calendar year as of May 2026.

Total NY MLTC enrollment 2026: ~280,000-300,000 members combined across all three product types. Many older sources cite 220,000-260,000, those are stale 2018-2022 figures. The 2026 operative range is approximately 250,000-270,000 in MLTCP, 25,000-30,000 in MAP, and 10,500 in PACE. Total annual public spending: ~$22 billion.

4. Who Must Enroll, Who Is Excluded

The mandatory population

A consumer must enroll in MLTC if they are:

1. Age 21 or older;
2. Dual-eligible (Medicaid + Medicare);
3. Reside in a mandatory-enrollment county (which now means anywhere in NY);
4. Will need community-based long-term services for more than 120 days; AND
5. Meet the September 2025 Minimum Needs Requirement (3+ ADLs limited assistance, or 2+ ADLs supervisory with documented dementia).

Voluntary populations

• Non-dual Medicaid-only adults 18+ needing CBLTSS for 120+ days.
• Adults 18-21 (cannot be mandatory-enrolled).
• Dual eligibles in non-mandatory counties (now effectively none, the mandate covers all 62 counties).

Excluded populations (PHL § 4403-f(7)(f))

• Children under 21 (children with PCS or CDPAP needs receive services through traditional FFS Medicaid, the Children's HCBS waiver, or Health Homes).
• Residents of OPWDD-certified residences (group homes, supervised IRAs).
• Residents of ICF/IID (intermediate care facilities for individuals with intellectual disabilities).
• Individuals with primary mental-health diagnoses eligible for HARP (Health and Recovery Plan).
• Certain immigration statuses (undocumented individuals with Emergency Medicaid only; PRUCOL recipients are eligible).
• Individuals participating in Comprehensive 1915(c) waivers, OPWDD HCBS waiver participants and NHTD and TBI 1915(c) waiver participants all remain in FFS Medicaid as of 2026.
• Hospice patients (election of hospice generally disenrolls the member from MLTC, with limited exceptions).
• Long-stay NF residents beyond the 3-month MLTCP coverage window.
• Expected to be Medicaid-eligible for less than six months.

The September 1, 2025 Minimum Needs Requirement, closer look

Under MLTC Policy 25.04 (issued June 30, 2025; revised August 22, 2025) and 25 OHIP/ADM-03, anyone enrolling in MLTCP or MAP on or after September 1, 2025 must (in addition to the 120-day duration test):

• Standard threshold: at least limited assistance with physical maneuvering with more than two ADLs (i.e., 3 or more of: bed mobility, transfer, locomotion in unit, locomotion outside unit, dressing, eating, toilet use, personal hygiene, bathing).
• Alzheimer's / Dementia threshold: at least supervision with more than one ADL (i.e., 2 or more), with documented diagnosis on file.

Legacy Status grandfather: Anyone enrolled in any MLTC plan (MLTCP, MAP, or PACE) prior to September 1, 2025 retains coverage at reassessment so long as they remain continuously enrolled. A break in enrollment forfeits Legacy Status, requiring re-qualification under the new threshold.

This is the single biggest narrowing of MLTC eligibility in a decade. Consumers who would have qualified before September 1, 2025 on the basis of significant IADL needs alone (managing medications, shopping, finances, meal preparation) without ADL needs no longer qualify under the new test.

NY Medicaid Choice, the enrollment broker

NY Medicaid Choice (NYMC), operated by Maximus Inc. under contract with NYSDOH, is the single statewide enrollment broker for MLTC.

• Phone: 1-855-222-8350 (MLTC enrollment) / 1-888-401-6582 (mainstream MMC).
• Website: nymedicaidchoice.com.
• Counseling: free, in-person and telephonic, available in 13+ languages plus interpreter access.

NYMC also operates the New York Independent Assessor Program (NYIAP), the same Maximus subsidiary handles both functions, which has drawn structural-conflict-of-interest commentary from advocates.

5. Enrollment Mechanics, From Application to Plan Selection

The standard pathway

1. Medicaid eligibility. The consumer must first be Medicaid-eligible (community Medicaid for non-NF members). If not yet eligible, they apply through the Local Department of Social Services (LDSS) or, in NYC, through HRA. Brevy's /medicaid/new-york/community-medicaid and /medicaid/new-york/how-to-apply cover this in depth.
2. NYIAP referral. Once Medicaid-eligible (or in some cases concurrently), the consumer or their representative calls NYMC at 1-855-222-8350 to request an MLTC assessment.
3. Community Health Assessment (CHA). A registered nurse from NYMC conducts a UAS-NY-driven assessment, in-person or telehealth depending on clinical complexity. Per 22 OHIP/ADM-01, scheduling must occur within 14 days.
4. Independent Practitioner Panel (IPP) Order. A physician, PA, or NP from the IPP issues a Practitioner's Order based on the CHA. This replaced the consumer's treating physician's order under pre-2022 rules.
5. Independent Review Panel (IRP), for high-need cases. Triggered when the CHA + PO indicate the consumer needs more than 12 hours/day of personal care or CDPAP services on average, including all live-in / 24-hour cases. The IRP applies an Olmstead v. L.C., 527 U.S. 581 (1999) safety-in-the-community standard.
6. Eligibility determination. NYIAP issues an Outcome Notice indicating MLTC eligibility (yes/no) and any service-level findings.
7. Plan selection. NYMC counselors help the consumer review available plans in their county, including supplemental benefits, network adequacy, and pharmacy partnerships.
8. Enrollment effective date. Generally the first of the next month after plan selection (or two months out depending on cut-off date).
9. Initial plan assessment. Upon enrollment, the plan must conduct its own care-plan assessment within 30 days. The plan must NOT redo the CHA, it must use the NYIAP CHA and PO as the basis for its plan of care.

Auto-assignment

If the consumer fails to select a plan after counseling, NYMC auto-assigns. Auto-assignment factors include plan availability in the consumer's county, plan compliance/quality scores, plan capacity (some plans operate under DOH-approved enrollment caps), and geographic and language appropriateness.

Plan switching and lock-in (MLTC Policy 21.04)

• First 90 days after enrollment, the consumer may switch plans for any reason ("grace period").
• Months 4-12 after enrollment, 9-month lock-in. Switches only for Good Cause as defined by NYSDOH.
• Month 13 and after, open to switch any time.
• After a Good Cause switch, a new 90-day grace period begins, followed by a new 9-month lock-in.

Good Cause categories:

1. Plan does not adequately serve the consumer's care needs.
2. Plan terminates or does not contract with the consumer's chosen provider, and continuity-of-care arrangements are inadequate.
3. Consumer moves out of the plan's service area.
4. Consumer's preferred provider is in a different plan's network.
5. Other reasons accepted by NYSDOH on a case-by-case basis.

Lock-in does NOT apply to PACE, PACE participants may disenroll at any time.

Disenrollment triggers (MLTC Policy 26.01, effective June 1, 2026)

MLTC Policy 26.01 standardizes the involuntary disenrollment process for all three product types beginning June 1, 2026. Plans must submit involuntary disenrollment packages to NYMC's Health Plan Affairs Department via secure portal. Triggers include:

• Hospitalization > 45 consecutive days without a discharge plan back to home.
• NF stay > 3 months in a non-MLTC NF (LTNHS designation triggers disenrollment for MLTCP, not MAP/PACE, to FFS Medicaid).
• Move out of plan's service area (or out of state).
• Loss of Medicaid eligibility.
• OPWDD residential placement > 45 days without an active discharge plan.
• Death of the member.
• Member request (voluntary, subject to lock-in).
• Member's behavior endangers others or makes service delivery impractical (rare; procedurally heavy).

6. What MLTC Covers, The Partial-Capitation Benefit Package

The operative source is Appendix K of the MLTC Model Contract, the "Covered/Non-Covered Services" matrix maintained by NYSDOH.

Core community-based long-term services and supports (CBLTSS):

• Personal Care Services (PCS), Level I (housekeeping; max 8 hr/wk per 18 NYCRR § 505.14(a)(5)) and Level II (housekeeping + ADL assistance). Authorized hours determined by the plan based on NYIAP CHA, IPP order, and IRP findings.
• Consumer Directed Personal Assistance Program (CDPAP), delivered through the statewide Fiscal Intermediary Public Partnerships LLC (PPL) since April 1, 2025. (Brevy's /medicaid/new-york/cdpap covers CDPAP in full.)
• Home Health Aide (HHA) services, through CHHA contracts.
• Skilled nursing in the home, PT/OT/ST in the home, through CHHA or LHCSA contracts.
• Private Duty Nursing (PDN), limited cases for medically complex members.

Day programs and respite:

• Adult Day Health Care (ADHC), medical model.
• Social Adult Day Care (SADC), non-medical model (subject to enhanced oversight per MLTC Policy 24.01).
• Respite, in-home and out-of-home; planned and emergency.

Residential alternatives:

• Assisted Living Program (ALP), Medicaid-funded subset of assisted living; the plan covers personal-care and home-care portions.

Institutional care (limited):

• Skilled Nursing Facility (NF), short stay, plan covers short-stay rehab and respite admissions.
• NF, long stay (LTNHS), plan covers the first 3 months of an LTNHS designation, then disenrolls the member to FFS Medicaid for institutional coverage. (NOT applicable to MAP/PACE.)

Therapies and ancillary clinical: audiology, podiatry, optometry (subject to plan benefit caps); dental (plan-specific scope); DME and medical/surgical supplies (hospital beds, wheelchairs, ostomy, incontinence, enteral formulas); nutritional supplements when medically necessary.

Transportation and care management:

• Non-Emergency Medical Transportation (NEMT), through NYSDOH's Medical Answering Services (MAS) for many regions; plan-specific in NYC.
• Care Management, required for every member; assigned care manager; written person-centered care plan.

Supplemental ("value-added") benefits vary by plan and are a primary plan-comparison factor: OTC allowance ($15-$60/quarter typical); healthy-foods allowance; vision hardware; hearing-aid allowances; acupuncture or chiropractic; telehealth platforms.

7. What MLTC Does NOT Cover, The Carve-Outs

Carved out of MLTCP and delivered through other channels:

• Inpatient hospital services, FFS Medicaid for MLTCP members; covered by Medicare for duals.
• Outpatient physician primary and specialty care, FFS Medicaid + Medicare for duals.
• Most retail-pharmacy prescription drugs, carved out to NYRx (the State's Medicaid PBM) effective April 1, 2023 for mainstream Medicaid managed care, HARP, and HIV-SNP. MLTCP, MAP, and PACE retained pharmacy under NYRx Phase II rules, i.e., MAP and PACE plans still administer the pharmacy benefit for their members. For MLTCP members specifically: most are dual-eligible and get pharmacy through Medicare Part D regardless (which means they don't experience the carve-out the way mainstream MMC members do); a smaller number of non-dual MLTCP members get pharmacy through NYRx FFS.
• Behavioral health (mental-health and SUD) services, carved into mainstream MMC or HARP for HARP-eligible adults.
• Family planning services, always available FFS, regardless of managed-care enrollment.
• OPWDD services, delivered through OPWDD's HCBS waiver; OPWDD-residence members are excluded from MLTC entirely.
• NHTD and TBI 1915(c) waiver services, delivered FFS (see Section 11 below).

The pharmacy carve-out scope is the single most-confused MLTC benefit question. A common error: writers describe NYRx as carving pharmacy out of "all" Medicaid managed care. Not so. The carve-out's actual effect on MLTCP members is minimal because most MLTCP members are dual-eligible and use Medicare Part D. MAP and PACE plans, which integrate Medicare, fully administer pharmacy through their D-SNP or PACE-on-site pharmacy arrangements.

8. Capitation Rate Structure and the MCO Tax

How plans get paid

Plans receive a per-member-per-month (PMPM) capitation payment computed by NYSDOH-contracted actuaries (typically Mercer or Milliman). The capitation amount varies by:

• Region, NYC (often subdivided by borough), Long Island, Hudson Valley, Capital, Western, Central, North Country, Finger Lakes.
• Member acuity, risk-adjusted using UAS-NY assessment data, mapped to one of 24 risk-cell categories by ADL count, IADL count, cognitive impairment, behavioral findings, and selected medical conditions.
• Product type, MLTCP rates are lower than MAP rates (which include Medicare integration); PACE rates are highest (most-comprehensive coverage).

NYSDOH's Bureau of MLTC Reimbursement (BMR) develops rates annually for the rate year beginning each January 1. CMS approves rates as part of the 1115 demonstration's actuarial soundness review under 42 CFR § 438.4.

The MCO Provider Tax (FY 2024-25 budget; CMS-approved December 20, 2024)

Part Y of Chapter 57 of the Laws of 2024 (FY 2024-25 enacted budget, signed April 20, 2024) created the NY MCO Provider Tax, modeled on California's CalAIM tax. Mechanics:

• Each MCO (including MLTC plans) pays a per-member-monthly tax to NYSDOH.
• NYSDOH deposits the proceeds in a "Healthcare Stability Fund."
• NYSDOH simultaneously increases capitation payments to those same MCOs.
• The increased capitation payments draw federal financial participation (FMAP) from CMS.
• The federal match is also deposited in the Healthcare Stability Fund.
• The Fund supports general Medicaid spending, hospital and nursing-home rate increases, FQHCs, and other purposes.

Projected revenue: $3.7 billion in new federal funding over the first two years.

Federal posture (December 20, 2024 CMS letter to NY State Medicaid Director Amir Bassiri): CMS warned that the tax "violates the spirit of federal law" and that "any future changes to the federal requirements concerning health care-related taxes may require the State of New York to come into compliance by modifying its tax structure." That warning has now been operationalized by OBBBA Section 71117.

OBBBA Section 71117, the existential threat to the MCO tax

The One Big Beautiful Bill Act (P.L. 119-21), enacted summer 2025, Section 71117:

• Freezes existing provider taxes at current levels (Section 71115 separately prohibits new provider taxes).
• Ratchets the safe-harbor cap from 6% of net patient revenue down to 3.5% by FY 2032 for ACA-expansion states (NY is an expansion state). The reduction is 0.5 percentage points per fiscal year starting FY 2028.
• Rewrites the "generally redistributive" test to prohibit differential rates based on Medicaid volume.
• CMS issued implementation guidance on November 18, 2025 (CMS Center for Medicaid and CHIP Services Informational Bulletin).

Implication for NY MLTC capitation: The MCO tax was designed inside the 6% safe harbor; reducing the cap to 3.5% by 2032 will shrink the tax's revenue substantially. NY's options are (a) restructure the tax to fit the lower safe harbor (with proportionally less revenue); (b) absorb the cut and reduce MLTC capitation rates; or (c) raise General Fund revenue to backfill. Empire Center, the Citizens Budget Commission, and the NYC Comptroller have all flagged this as a multi-billion-dollar fiscal exposure for NY Medicaid through 2032.

The 2025-2026 MCO tax payment timing dispute

Crain's New York Business reported in 2025 that NY had delayed multiple quarterly MCO tax disbursements to plans, drawing federal scrutiny. By early 2026, the state had brought disbursements current but the underlying cash-flow pressure remains an operational risk.

9. Plan-Level Utilization Management and Authorization

Service authorization timeframes, the January 1, 2026 change

For rating periods through December 31, 2025:

• Standard authorization: plan must decide within 14 calendar days (extendable by 14 additional days for the enrollee's benefit).
• Expedited authorization: plan must decide within 72 hours when standard timeframe could "seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function."

For rating periods beginning on or after January 1, 2026 under the CMS Interoperability and Prior Authorization Final Rule:

• Standard authorization: plan must decide within 7 calendar days.
• Expedited authorization: 72 hours (unchanged).

This change applies to MLTCP, MAP, and PACE alike. NYSDOH-issued GIS guidance in late 2025 conformed state expectations to the federal rule.

Internal appeals (42 CFR § 438.402; 18 NYCRR § 360-10.8)

• Standard appeal: plan must resolve within 30 calendar days of receipt; extendable by 14 days.
• Expedited appeal: plan must resolve within 72 hours of receipt; extendable by 14 days for enrollee's benefit.
• Filing window: enrollee must file within 60 calendar days of the date of the plan's adverse benefit determination notice.

Aid Continuing during appeals

If the consumer files an appeal before the effective date of the action OR within 10 days of the plan's notice of action (whichever is later), services continue at the previously-authorized level pending appeal resolution. If the consumer loses the appeal, the plan may seek recoupment of aid-continuing payments in some circumstances, though in practice recoupment is rarely pursued for MLTC consumers.

Service overlap with NYIAP IRP for cases averaging 12+ hours/day

The NYIAP Independent Review Panel framework runs in parallel with, but does not replace, plan-level utilization management. For cases > 12 hr/day:

1. The IRP panel sets a "consistent with safety" determination.
2. The plan then conducts its own utilization review and may authorize fewer hours than the IRP "ceiling" if its medical-necessity review concludes fewer hours suffice.
3. If the plan's authorization is below the IRP-indicated need, the consumer may appeal at the plan level, then to fair hearing, then to Article 78 proceedings.

Plan-level CDPAP overtime authorization variability

Plans vary substantially in their willingness to authorize CDPAP PA overtime (a single PA working > 40 hours/week, requiring overtime pay). Some plans require split-shift staffing (multiple PAs); others authorize one PA working overtime if the consumer prefers continuity. There is no statewide overtime-authorization rule, each plan's policy is in its provider manual and is a major plan-comparison factor for high-need consumers.

10. NYSDOH MLTC Policy Directives 2024-2026

MLTC Policy directives are issued by NYSDOH Bureau of Managed Long Term Care; OHIP/ADM directives are issued by the Office of Health Insurance Programs and bind LDSSes (county Medicaid offices). They are functionally complementary and frequently issued in tandem on the same operational subject. NYSDOH's MLTC Policy index is at health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm, verify any pending 2026 directives before relying on this list.

11. The NHTD/TBI MLTC Carve-Out Question

NHTD (Nursing Home Transition and Diversion) and TBI (Traumatic Brain Injury) are 1915(c) HCBS waivers operated by NYSDOH (separate from OPWDD waivers). They serve people who would otherwise need nursing-home or specialty rehab placement.

Both NHTD and TBI remain CARVED OUT of MLTC in 2026, i.e., participants receive services FFS, not through an MLTC plan.

Legislative and administrative timeline:

• 2018-2024: multiple administrative target dates for NHTD/TBI carve-INTO MLTC; all repeatedly delayed.
• 2025 session: S806 / A1349 (Rivera/Gunther), would permanently carve out the TBI waiver and extend the NHTD carve-out through April 1, 2027. As of May 2026, passed Senate Health Committee; pending Assembly action.
• FY 2025-26 Executive Budget: Hochul administration proposed carving NHTD into MLTC. Not adopted in the FY 2026 enacted budget (April 28, 2025 budget agreement). The FY 2026 enacted budget instead included an "Exclusion of Permanent Placement Nursing Home Residents from Partial MLTC" (codifying the existing 3-month NF rule).
• Most recent administrative target for NHTD carve-IN: January 1, 2027 (per LeadingAge NY testimony at the February 2, 2026 Joint Legislative Budget Hearing).
• NHTD enrollment cap concerns: NHTD has an administrative enrollment cap of 9,400 participants. Despite the cap, enrollment reached approximately 10,200 in December 2025 and an estimated 12,700 by mid-January 2026 (Alliance of TBI/NHTD Waiver Providers testimony).

For consumers reading this article in 2026: NHTD and TBI participants do NOT enroll in MLTC. Their personal-care-equivalent services are billed FFS. If a consumer needs help with both an NHTD waiver service (e.g., service coordination, structured day program) AND an MLTC-style benefit package, they cannot receive both simultaneously, they choose one or the other, and that choice is a major care-planning decision. The carve-IN scheduled for January 1, 2027 will likely change this; flag the 2027 transition as a potential update.

12. MLTC for Long-Stay Nursing-Home Members

The 3-month MLTCP rule

Per PHL § 4403-f(7-a) and the 2020 1115 demonstration amendment:

• An MLTCP member admitted to an NF gets up to 3 months of NF coverage from the MLTCP plan if designated as Long Term Nursing Home Stay (LTNHS).
• After 3 months, the member is disenrolled to FFS Medicaid for ongoing institutional coverage.
• The 3-month clock starts the first day of the month following the LTNHS designation (LDSS-3559 form executed by the NF and authorized by the plan).
• The rule does NOT apply to MAP, PACE, or FIDA-IDD, those plans retain full institutional coverage as part of their integrated benefit.

Interaction with 2026 Medicaid lookbacks

• Institutional Medicaid (NF coverage): 5-year lookback under 42 USC § 1396p(c) and 18 NYCRR § 360-4.4. Unchanged in 2026.
• Community Medicaid (CBLTSS): 30-month lookback enacted in 2020 but still NOT implemented as of May 2026. The federal COVID-era prohibition on Medicaid cuts blocked implementation through 2024; even after that prohibition lifted in early 2025, NYSDOH has not finalized implementation rules. The most recent NYSDOH guidance pushes effective dates to "no earlier than 2025-2026" but as of May 2026 no enforcement date has been set. (Brevy's /medicaid/new-york/30-month-lookback covers this in depth.)
• For MLTC enrollment: MLTC members generally apply for community Medicaid, not institutional. When an MLTCP member is disenrolled to FFS for long-stay NF, they must re-apply (or be re-determined) for institutional Medicaid, which DOES use the 5-year lookback. The transition often surfaces transfer-penalty problems that did not exist when the member was on community Medicaid.

FY 2026 budget, "Exclusion of Permanent Placement Nursing Home Residents from Partial MLTC"

The FY 2026 enacted budget (April 28, 2025) codified, but did not significantly change, the existing rule that LTNHS-designated members are excluded from MLTCP after 3 months. The provision was framed as an MCO-cost-control measure: keeping permanent NF residents off MLTCP capitation rolls.

13. Fair Hearings, Aid Continuing, and Consumer Rights

Three-layer appeal architecture

1. Plan internal appeal, under 42 CFR § 438.402 and 18 NYCRR § 360-10.8. Filing window: 60 days from notice. Resolution: 30 days standard, 72 hours expedited.
2. External Review, for clinical-necessity denials. Available under NY Public Health Law § 4914. NYSDOH External Appeal Agent. Filing window: 4 months from final adverse determination.
3. Fair Hearing, under 18 NYCRR Part 358 and Soc. Serv. Law § 22. Operated by NY OTDA Office of Administrative Hearings. Filing window: 60 days from notice.

Important MLTC-specific procedural protection: As of policy changes circa 2018-2020, MLTC enrollees may request a State Fair Hearing without first exhausting the plan's internal appeals process for service authorization denials. (Mainstream MMC retained the exhaustion requirement.)

Aid Continuing, 18 NYCRR § 358-3.6

Aid Continuing is the right to continued services at the previously-authorized level pending appeal resolution. Triggers:

• The consumer has filed a State Fair Hearing request (NOT just an internal plan appeal, aid continuing requires a Fair Hearing request).
• The request was filed before the effective date of the adverse action OR within 10 days of the agency's mailing of the notice (whichever is later).
• The challenged action involves termination, suspension, or reduction of previously-authorized services.

Mayer v. Wing notice-adequacy case law

Mayer v. Wing, 922 F. Supp. 902 (S.D.N.Y. 1996), is the foundational case on what constitutes adequate notice when reducing home-care services. Holdings:

• Notice must state the specific reason for the reduction.
• Acceptable reasons are: (1) change in medical/mental/economic/social circumstances; (2) prior-authorization mistake; (3) consumer's refusal to cooperate with reassessment; (4) technological change rendering services unnecessary; or (5) finding that the consumer can be more cost-effectively served through alternative Medicaid programs.
• Notice that simply states "reassessed need" without specific factual basis violates due process under the 14th Amendment.

The plaintiff class won injunctive relief; the Mayer notice standards remain binding on NYC and have been operationalized statewide through MLTC notice templates issued by NYSDOH.

Consumer-rights resources

• ICAN (Independent Consumer Advocacy Network), the statewide ombudsman for Medicaid managed care (MLTC, MMC, MAP, PACE, HARP). Funded under NY Aging Law / Soc. Serv. Law. Phone: 1-844-614-8800. Website: icannys.org. ICAN is hosted by Community Service Society of NY with regional partners (CIDNY, Legal Services of Long Island). Independent of NYMC, which gives it structural neutrality NYMC lacks.
• NYLAG (New York Legal Assistance Group), Medicaid managed-care advocacy and litigation; lead counsel in Engesser; runs the MLTC Data Transparency Project.
• The Legal Aid Society (NYC), represents low-income consumers in MLTC fair hearings.
• Empire Justice Center, statewide policy advocacy and consumer education.
• Selfhelp Community Services, direct consumer assistance for older adults in NYC.
• Mobilization for Justice (formerly MFY Legal Services).

14. The 2025-2026 MLTC Enrollment Reality and the Engesser Effect

Total MLTC enrollment 2025-2026: ~280,000-300,000 (NYLAG cites "nearly 300,000"). Distribution: ~250,000-270,000 in MLTCP; ~25,000-30,000 in MAP; ~10,500 in PACE. Total annual public spending: ~$22 billion.

Top 5 MLTCP plans by enrollment (rank order shifts quarterly):

1. VNS Health MLTC (statewide nonprofit; absorbed Prime Health Choice in 2025).
2. Centers Plan for Healthy Living (Centers Health Care).
3. Healthfirst Senior Health Partners (NYC hospital-sponsored nonprofit).
4. Fidelis Care at Home (Centene Corp.; statewide).
5. Senior Whole Health of NY (Molina Healthcare; statewide).

Enrollment trend 2024-2026:

• 2024: enrollment continued growth from post-pandemic lows; total approached 290,000.
• 2025 Q1-Q3: growth slowed as the September 1, 2025 Minimum Needs Requirement loomed; new applications spiked in July-August ahead of the threshold change.
• 2025 Q4: new enrollment fell sharply post-September 1 as the higher threshold filtered out lower-acuity applicants. Existing members protected by Legacy Status; total enrollment held roughly flat.
• 2026: new enrollment running below 2024 levels; Legacy enrollees continue to disenroll through normal attrition (death, NF placement, move out of state); total enrollment expected to decline modestly through 2026 unless the threshold is loosened.

The Engesser settlement's indirect MLTC effect

Engesser et al. v. McDonald, 1:25-cv-01689 (E.D.N.Y., Hon. Frederic Block, J.) was the class action that challenged the loss of CDPAP services during the April 1, 2025 PPL transition. The settlement does NOT directly govern MLTC plan operations, but it has two indirect effects on MLTC:

1. Notice and aid-continuing protections for MLTC members whose CDPAP services were disrupted during transition. Class members include MLTC enrollees who lost CDPAP services without proper notice.
2. Coordination requirements between MLTC plans and PPL, articulated in MLTC Policy 25.03 (February 26, 2025), that flow through to plan-level care management and authorization timeliness.

Final approval of the Engesser settlement was October 3, 2025 (ECF No. 140); the case remains under court supervision through implementation. (Brevy's /medicaid/new-york/cdpap is the primary source on Engesser.)

Long-term sustainability, three converging pressures

1. OBBBA Section 71117 ratchets the MCO-tax safe harbor from 6% to 3.5% by 2032, directly reducing the federal-match base for MLTC capitation.
2. OBBBA Sections 71113-71114 create administrative burden through 6-month redeterminations for ACA expansion adults (mostly NOT MLTC members but adds general Medicaid administrative load).
3. The Home Care Savings & Reinvestment Act (S2332-A / A6346-A), if enacted, would eliminate MLTCP entirely April 1, 2028 or upon Commissioner of Health certificate of readiness, note: many advocacy and trade-press summaries written in early 2025 still cite the originally-floated April 1, 2026 effective date, which the latest amendment moves to 2028.

If any two of those three pressures materialize fully, NY MLTC capacity contracts substantially. The 2026-2028 horizon is one of structural uncertainty, not settled status quo.

15. OBBBA Federal-Policy Effects on MLTC

Aggregate fiscal pressure: OBBBA is projected to reduce federal Medicaid spending nationally by roughly $700 billion–$1 trillion over 10 years. NY's share has been estimated at $13–17 billion through 2032 by the NYC Comptroller and Empire Center; a meaningful portion hits MLTC capitation through Section 71117.

16. Practical Guidance for Families

How to compare plans

In rough order of importance:

1. Network adequacy for the consumer's existing providers. Is the consumer's current home-care agency (LHCSA), primary-care doctor (for MAP/PACE), and specialists in the plan's network? Continuity-of-care rules under MLTC Policy 19.02 require 90 days of continuity post-enrollment, but after that, network gaps can force provider changes.
2. CDPAP overtime authorization policy. For members with 24-hour or live-in CDPAP arrangements, plan willingness to authorize PA overtime (versus splitting shifts) is decisive.
3. Authorization timeliness and appeal patterns. NYLAG's MLTC Data Transparency Project and NYSDOH's MLTC Performance Tables surface plan-level appeal-resolution data. Plans with high adverse-determination rates and low appeal-reversal rates are red flags.
4. Supplemental benefits. OTC allowance, healthy-food allowance, vision/dental hardware, transportation beyond NEMT minimums.
5. Care-management quality. Member-facing care-manager turnover; care-manager-to-member ratios; member-experience surveys.
6. Plan size and stability. Smaller plans have closed (ICS 2019, Prime Health Choice 2025); larger plans have more stability but less personalized care management.

The free counseling resources

NY Medicaid Choice (Maximus), 1-855-222-8350. Free counseling in 13+ languages. NYMC counselors will not recommend a specific plan but will explain coverage, networks, and supplemental benefits in detail.

ICAN (Independent Consumer Advocacy Network), 1-844-614-8800. Free, independent, non-plan-affiliated ombudsman. Helps consumers resolve plan disputes, file appeals, and represent themselves in fair hearings. Structurally independent from NYMC.

Comparison tools

• NYMC's Find a Long-Term Care Plan tool, nymedicaidchoice.com/en/find-long-term-care-plan, by-county plan list with limited supplemental-benefit info.
• NYLAG's MLTC Data Transparency Project, nylag.org/mltcdatatransparency/, financial and authorization data by plan.
• NYSDOH MLTC Performance Tables, health.ny.gov/health_care/managed_care/mltc/tables/, quality metrics by plan (HEDIS-equivalent QARR).

Common pitfalls

1. Lock-in confusion. Many consumers don't realize that after the 90-day grace period, they're locked in for 9 months without Good Cause.
2. Pharmacy carve-out confusion. MLTCP members frequently believe their plan handles their retail pharmacy; in fact, most do not (because most members are dual and use Medicare Part D, or are non-dual and use NYRx). MAP and PACE members get integrated pharmacy.
3. NF transition surprises. A 3-month NF stay quietly triggers MLTCP disenrollment to FFS, often without the family realizing the change in coverage rules until institutional Medicaid lookback issues surface.
4. Auto-assignment to a plan with poor network for the consumer's providers. Failing to engage with NYMC counseling within the assignment window forfeits choice.
5. Loss of Legacy Status. Pre-September 1, 2025 enrollees protected from the Minimum Needs Requirement only while continuously enrolled. A short-term move out of state, an extended LTNHS hospital stay, or a voluntary disenrollment can permanently forfeit Legacy Status.
6. Conflating MLTC with mainstream MMC. These are different programs with different eligibility, networks, and benefits. PACE and MAP integrate; MLTCP does not.

17. Frequently Asked Questions

A few more common questions:

Can I keep my current home-care agency if I enroll in MLTC? Sometimes. If your agency is in your chosen plan's network, yes. If not, MLTC Policy 19.02 requires 90 days of continuity-of-care post-enrollment, after which you may need to switch to an in-network agency. This is a key plan-comparison factor.

Will I lose CDPAP if I switch MLTC plans? Generally no, your PA is employed by Public Partnerships LLC (PPL), which operates statewide, so the PA relationship doesn't change with plan switches. What can change is the authorized number of hours, because the new plan will conduct its own utilization review.

What happens if I go into a nursing home? For MLTCP members: your plan covers the first 3 months of an LTNHS stay, then disenrolls you to FFS Medicaid for ongoing institutional coverage. For MAP and PACE: your plan covers the full stay. The transition often surfaces 5-year-lookback issues that didn't exist while you were on community Medicaid.

Do MLTC plans cover prescription drugs? For most members: no, because most MLTCP members are dual-eligible and use Medicare Part D for prescriptions. MAP and PACE integrate Part D into the plan. The April 2023 NYRx carve-out moved retail pharmacy out of mainstream MMC, HARP, and HIV-SNP, but MLTCP-enrolled duals were already on Part D, so the carve-out had little practical effect on them.

How long does it take to get enrolled? 2-6 weeks from initial NYMC call to plan effective date, including the NYIAP CHA + IPP order (2-4 weeks) and plan selection (1-2 weeks). Expedited processing is available for hospital discharges and rapidly deteriorating conditions.

Are NHTD or TBI waivers part of MLTC? Not in 2026. Both remain carved out as FFS waivers. Administrative carve-IN target: January 1, 2027.

Will MLTC still exist in 2027 or 2028? Uncertain. The 1115 MRT demonstration expires March 31, 2027 with renewal application due April 1, 2026 (not yet posted in final form as of May 2026). S2332-A would repeal MLTCP entirely effective April 1, 2028 (or earlier upon a Commissioner of Health certificate of readiness). OBBBA Section 71117 is shrinking the federal-match base. The 2026-2028 horizon is one of structural uncertainty.

18. Resources and Contacts

NY Medicaid Choice (NYMC), 1-855-222-8350 (MLTC) / 1-888-401-6582 (mainstream MMC); nymedicaidchoice.com.

ICAN (Ombudsman), 1-844-614-8800; icannys.org.

NYSDOH Bureau of Managed Long Term Care, Plan directory at health.ny.gov/health_care/managed_care/mltc/mltcplans.htm; Policy index at health.ny.gov/health_care/medicaid/redesign/mrt90/mltc_policies.htm.

NY OTDA Office of Administrative Hearings, 1-800-342-3334; otda.ny.gov/oah/.

NYSDOH NYIAP, health.ny.gov/health_care/medicaid/redesign/nyiap/.

Legal services:

• NYLAG: nylag.org
• Legal Aid Society (NYC): legalaidnyc.org
• Empire Justice Center: empirejustice.org
• Mobilization for Justice: mobilizationforjustice.org

NY Connects (statewide referrals to legal aid and aging services): 1-800-342-9871.

Learn More

• New York Community Medicaid
• How CDPAP Pays You to Care for a Loved One in New York
• New York Medicaid Advantage Plus (MAP)
• New York Medicaid Eligibility & Income Limits
• New York Pooled Income Trusts
• How to Apply for New York Medicaid

Find personalized help navigating New York Managed Long Term Care at brevy.com.

The information on Brevy.com is for educational purposes only and is not a substitute for professional legal, financial, or medical advice. Rules vary by state and program and change frequently. Always verify with the relevant agency or a qualified professional. Brevy is not a law firm, financial advisor, or healthcare provider.