Continuity of Care Exception to LHCSA Cap Expanded
The Department of Health (DOH) announced last week in a Dear Administrator Letter (DAL) that it will not count toward the licensed home care services agency (LHCSA) contract cap those contracts with managed long term care (MLTC) plans that are executed to continue care to enrollees in plans that have closed, merged, or reduced their service area. Since Oct. 1st, partially-capitated MLTC plans have been limited in the number of LHCSAs they may include in their networks. In 2018, in the downstate region, MLTC plans are limited to one LHCSA per 75 enrollees, and in the rest of the state, MLTC plans are limited to one LHCSA per 45 enrollees.
However, these numeric limits are subject to certain exceptions that are intended to ensure that enrollees experience continuity of care and have adequate access to services. By statute, if an enrollee wishes to be cared for by one or more home care workers employed by a LHCSA with a contract that will be terminated, the MLTC plan may continue the contract for the purpose of continuing that enrollee's care by those home care workers for up to three months. In addition, the MLTC may seek an exception if it must exceed the contract limit in order to ensure adequate access to services in a geographic area, including access to special needs services and services that are culturally or linguistically appropriate.
According to the DAL, the continuity of care exception includes contracts based on the plans' obligation to provide continuity of care with the same provider for 90 days when the enrollee is transitioned from fee-for-service to MLTC and for 120 days when the enrollee is transferring to a new plan due to plan closure, service area reduction, or merger/acquisition or similar transaction. Plans are permitted to enter into "single case agreements" with LHCSAs under these circumstances and exclude the agreements from the calculation of the maximum number of LHCSAs in their network during the applicable continuity of care period. After expiration of the continuity of care period, whether it is 90 or 120 days, the contract will be counted in determining whether the LHCSA network limit has been exceeded. Plans may not seek an additional three-month continuity of service exception following a single case agreement that was entered into for the purposes of continuity of care. MLTC plans are required to report these single case agreements to the Department.
The Department has asked MLTC plans to submit "LHCSA Network Survey" spreadsheets detailing current contracts and those that are being terminated. In addition, plans have 15 days to update and resubmit their PNDS files after a provider is terminated. “Continuity of Service and Continuity of Care Reporting” spreadsheets should be completed with all single case agreements and submitted here by Dec. 20, 2018. Additional information is available here.