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Medicaid Residential Health Care Facilities Benefit for Members

Rehabilitation:

WellCare covers short-term (or rehab) stays in a skilled nursing home facility.

Long-Term Placement:

Beginning February 1, 2015, WellCare will also cover long-term placement in a nursing home for members 21 years of age and older who live in New York City. 

Long-term placement in a skilled nursing home will be added to the Medicaid Managed Care benefit package in phases. It is anticipated that by July 1, 2015, long-term placement in a nursing home will be covered for residents statewide who are age 21 years and older. 

Eligible Veterans, Spouses of Eligible Veterans, and Gold Star Parents of Eligible Veterans may choose to stay in a Veterans’ nursing home. 

Covered nursing home services include:

  • Medical supervision
  • 24-hour nursing care
  • Assistance with daily living
  • Physical therapy
  • Occupational therapy
  • Speech-language pathology and other services 

For a member to obtain these nursing home services:

  • They must be ordered by a physician and authorized by WellCare 

The member must also be found financially eligible for long-term nursing home care by his/her County Department of Social Services in order to have Medicaid and/or WellCare pay for these services.  

When a member is eligible for long-term placement, he/she must select a nursing home that is in WellCare’s network. 

If the member wishes to live in a nursing home that is not part of WellCare’s network, he/she may transfer to another plan that works with the nursing home he/she has chosen to receive his/her care.   

WellCare does not have a Veterans’ nursing home in its network. If a member is an Eligible Veteran, a Spouse of an Eligible Veteran, or a Gold Star Parent of an Eligible Veteran and he/she wishes to live in a Veterans’ nursing home, he/she may transfer to another Medicaid Managed Care health plan that has a Veterans’ nursing home in its network. 

If you have any questions about these benefits, call our Provider Services Department at 1-800-288-5441.

Disenrollment and Transfers 

When members enroll in WellCare, they have 90 days (three months) to decide if they wish to stay in our plan, or leave our plan and enroll in another Medicaid Managed Care health plan. 

After the 90 days, the member must stay in our plan for nine more months, unless the member has a good reason (Good Cause) to disenroll from our plan. 

Some examples of Good Cause include: 

  • Our health plan does not meet New York State requirements, and members are harmed because of it.
  • The member moves out of our plan’s service area.
  • The member, the plan and the LDSS all agree that disenrollment is best for the member.
  • The member is or becomes exempt or excluded from managed care.
  • We do not offer a Medicaid managed care service that the member can get from another health plan in his/her area.
  • The member needs a service that is related to a benefit we have chosen not to cover and getting the service separately would put the member’s health at risk.
  • We have not been able to provide services to the member, as we are required to under our contract with the State.
  • The member is a child that has entered foster care at the LDSS and needs to transfer to a new plan to see the appropriate providers.
  • We do not have a contract with the nursing home the member is living in or is going to live in, and the member needs to transfer to a plan that does.
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Last Updated On: 10/5/2015
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