Minimum LTSS Eligibility Criteria for MLTC Partial Capitation (MLTCP)
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Defines updated Minimum LTSS eligibility criteria for new and returning enrollees to VNS Health MLTC Partial Capitation (MLTCP) effective Sept 1, 2025; affects members seeking enrollment or re-enrollment in MLTC plans administered by VNS Health.
Effective September 1, 2025, new enrollees must be assessed as needing community-based long term services and supports (CBLTSS) for more than 120 days and meet specified minimum needs.
Minimum needs defined as either limited assistance with two or more ADLs due to physical mobility limitations, or a diagnosis of dementia or Alzheimer’s with supervision needs for at least one ADL.
Existing enrollees continuously enrolled before Sept 1, 2025 will not be subject to the new minimum needs at re-assessment unless they disenroll and later seek re-enrollment.
Minimum LTSS Enrollment Criteria (MLTCP)
MLTCP Minimum Needs Criteria
Minimum enrollment criteria for new MLTCP enrollees (effective 9/1/2025):
AND one of the following must be met:
- Limited assistance with two or more activities of daily living (ADLs) due to physical mobility limitations
- Diagnosis of dementia or Alzheimer’s with supervision need for at least one ADL
Grandfathering: Members continuously enrolled before September 1, 2025 are not subject to the new minimum needs at reassessment; members who disenroll and later seek re-enrollment must meet the current criteria.
Coding & Timing Details
Provider Assessment and Documentation Requirements
MLTC enrollment assessment requirements
Assess every prospective enrollee for need of community-based long term services and supports (CBLTSS) for more than 120 days and document that they meet one of the following minimum needs: (a) limited assistance with two or more activities of daily living (ADLs) due to physical mobility limitations, or (b) a diagnosis of dementia or Alzheimer’s requiring supervision for at least one ADL. Members continuously enrolled before September 1, 2025 are not subject to these new minimum needs at reassessment; members who disenroll and later seek re-enrollment must meet the current criteria.
- Assessment must indicate need for CBLTSS for >120 days.
- Document either: limited assistance with ≥2 ADLs due to physical mobility limitations, or diagnosis of dementia/Alzheimer’s with supervision need for ≥1 ADL.
- Grandfathering: continuous enrollees before 9/1/2025 are exempt from the new minimums at reassessment; disenrolled members seeking re-enrollment must meet the new criteria.
Key Terms
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