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New DOH Policies for Managed Long Term Care Plans, Home Care and Hospice

Last week, the Department of Health (DOH) released several new managed care policies for home care and hospice and a Frequently Asked Questions document on hospice.

1.)  MLTC Policy 15.09: Changes to the Regulations for Personal Care Services (PCS) and Consumer Directed Personal Assistance (CDPA), effective Dec. 23, 2015. 

The purpose of this policy is to inform Managed Long Term Care Plans (MLTCPs) of revisions to the Personal Care Services (PCS) and Consumer Directed Personal Assistance (CDPA) regulations, 18 NYCRR § 505.14 and 18 NYCRR § 505.28, respectively.

Both of these revised regulations were effective on Dec. 23, 2015.

These changes to the PCS and CDPA regulations include:

  • changes to the definitions and eligibility requirements for continuous (“split-shift”) PCS;
  • repeal of the entire definition of “some assistance” and “total assistance”;
  • adding “turning and positioning” to level II personal care function and as a CDPA function;
  • the nursing assessment is no longer required to include an evaluation of the degree of assistance required for each task or function because of the repeal of definitions “some assistance” and “total assistance”; and  
  • changes to the definitions and eligibility requirements for CDPA as well as live-in 24-hour PCS and CDPA.

This policy directs MLTCPs to be aware of, and apply, effective immediately, the revised definitions and eligibility requirements when conducting PCA and CDPA assessments and reassessments. According to the new policy, the revised regulations set forth criteria for notices that deny, reduce or discontinue these services. See the revised regulations:

  • 505.14(b)(5)(v) - this provision governing social services districts’ gives notice to recipients for whom districts have determined to deny, reduce or discontinue PCS are revised and reorganized.
  • 505.28(h)(5) - is amended to provide additional detail regarding the content of social services district notices when the district denies, reduces or discontinues CDPA.

See the attached detailed summary of these changes and the Notice of Adoption, as published in the New York State Register on Dec. 23, 2015 on page twelve.

The new policy directs MLTCPs to ensure that their policies and procedures are appropriate and updated to reflect these new requirements.

If you have any questions regarding this new policy, please email the Bureau of Managed Long Term Care at mltcworkgroup@health.ny.gov.

2.)    MLTC Policy 13.18(b) - MLTC Guidance on Hospice Coverage Update:

The purpose of this policy is to clarify for Managed Long Term Care (MLTC) plans coverage of, and billing for, hospice services provided to existing MLTC enrollees who are residents in either, a skilled nursing facility or a hospice residence.

According to the new policy, “Any MLTC enrollee who requires hospice services and meets hospice eligibility requirements may elect the benefit without disenrolling from their MLTC plan. For MLTC enrollees (Partial Capitation MLTC and Medicaid Advantage Plus), hospice services (with the exception of daily room and board charges) are not included in the plan benefit and are billable directly to Medicare and Medicaid as appropriate.”

In the policy it restates, individuals already enrolled in hospice remain excluded from enrolling into MLTC plans. MLTC enrollees in receipt of hospice services are not prohibited from transferring to another MLTC plan.

3.) Hospice and Managed Long Term Care – Frequently Asked Questions (FAQs)

The Department of Health in an effort to help clarify some of the questions that have arisen as part of the nursing home transition to managed care has released FAQs, in addition to the new MLTC Policy 13.18(b).  DOH believes there has been some confusion with regard to the coverage of and billing for hospice services under Managed Long Term Care (MLTC); specifically in relation to those MLTC plan enrollees residing in a nursing facility or a hospice residence.

Contact: Cheryl Udell, cudell@leadingageny.org, 518-867-8871