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LeadingAge NY Advocates for Provider-Sponsored Care Management

LeadingAge NY asked the Department of Health (DOH) last week to reconsider its proposed approach to federal care management requirements in relation to the Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) Waivers. In addition, we urged the Department to ensure that, as NHTD, TBI, and Community First Choice Option (CFCO) services are incorporated into managed care, its implementation of these federal regulations would not interfere with the continued viability of provider-sponsored managed care plans, PACE programs, and care management entities.

Federal home and community-based services (HCBS) regulations prohibit providers of HCBS, or those that have an interest in or are employed by a provider of HCBS, from providing case management or developing person-centered service plans, except when the state demonstrates that the only willing and qualified entity to do so in a geographic area also provides HCBS. Known as "conflict of interest" (COI) regulations, these provisions are intended to ensure that service plans are developed by entities that do not have an interest in the delivery of certain types or levels of services or certain providers. The COI regulations apply to waiver services under Social Security Act section 1915(c), section 1915(i) state plan services, and CFCO services.

On July 7th, in response to these regulations, the Department notified TBI and NHTD waiver stakeholders that “effective April 1, 2018, any Service Coordinator or Service Coordination Provider agency will be restricted from providing any other waiver services unless the State demonstrates that the provider meets the exemption standards for rural and/or cultural accommodations.” More recently, the Department indicated that its COI corrective action plan for these waivers has been approved by the Centers for Medicare and Medicaid Services (CMS).

In a letter to the Department, LeadingAge NY asked the Department to follow the precedent set by Health Homes and allow entities that are both NHTD and TBI Service Coordinators and HCBS providers to conduct person-centered service planning, care coordination, and provision of HCBS, “as long as firewalls are constructed between the service planning, care coordination, and service provision.” Further, we requested that provider-sponsored managed care plans and their provider-operated care management subcontractors be allowed to carry out these functions, provided that firewalls are constructed between service planning and service provision. Finally, we asked that PACE programs, as fully-integrated, staff model managed care programs, be exempt from the COI rules.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383 ext. 124