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Independent Assessor for MLTC, Personal Care, CDPAS Launches

The Department of Health (DOH) provided updates and responded to questions last week in advance of the launch of the independent assessor process for personal care services (PCS), Consumer Directed Personal Assistance Services (CDPAS), and Managed Long Term Care (MLTC). Initial independent assessments to qualify for these programs, as well as independent practitioner examinations, and clinical reviews of high-needs cases, began on May 16th. The Conflict-Free Evaluation and Enrollment Center (CFEEC) is being eliminated and replaced by the New York Independent Assessor (NYIA).

There are some important exclusions from the scope of the NYIA. It does not cover applicants for or enrollees in Programs of All-Inclusive Care for the Elderly (PACE programs), nor does it apply to prospective or existing residents in Assisted Living Programs (ALPs).

The roll-out of the NYIA will, until further notice, apply only to initial assessments. MLTC plans will no longer conduct a separate Uniform Assessment System (UAS) community health assessment (CHA) of individuals seeking to enroll in the plan. MLTC plans are also expected to continue to evaluate new enrollees as part of the development of the plan of care (POC). This will not involve a UAS CHA, but will entail some form of assessment.

In addition, MLTC plans will continue to conduct the following CHAs until notified otherwise:

  • Routine and annual reassessments for authorizing PCS and/or CDPAS;
  • Non-routine reassessments, as needed, including
    • return from institutional care assessments;
    • significant change in condition assessments;
    • assessments at the individual's request.
  • MLTC Plan-to-Plan transfer assessments, if the last assessment was conducted by the prior plan.

If the applicant's assessment was in process before May 16th, it will proceed under the prior program rules. The CFEEC will conduct an assessment, the applicant will obtain the practitioner order, and the MLTC plan will conduct its own CHA for care planning purposes.

Only individuals with active Medicaid will be able to receive a CHA. Individuals who have not been determined eligible for Medicaid will be referred to the local department of social services (LDSS) to apply for Medicaid. The NYIA will receive requests to schedule CHA appointments through its Helpline, and it will schedule both the CHA and the clinical appointment within 14 days of initial contact. The Helpline will verify the customer's identity, preferred assessment modality (in-person or virtual), and the location of the visit, if in-person. If the consumer asks to reschedule the appointment, the 14-day clock will be reinitiated.

In addition to launching initial assessments, the Department is launching the independent practitioner order process. The independent practitioner will issue the practitioner order indicating whether there is a need for services, whether the individual is self-directing and able to receive services safely in the home, and whether the individual is medically stable to receive PCS or CDPAS.

Upon completion of the CHA and the independent medical exam, the individual will receive a notice indicating whether they are eligible for MLTC enrollment and whether they are medically stable to qualify for PCS and/or CDPAS. If the individual is not eligible or not medically stable, the individual will receive a notice and fair hearing information. However, the individual may still qualify for MLTC enrollment if other community-based services may address the individual's needs.

For new applicants on or after May 16th, if the MLTC plan proposes a POC with more than 12 hours per day of CDPAS and/or PCS on average, and the applicant agrees to the POC, the MLTC plan must refer the case to the NYIA independent review panel (IRP). Hours of care delivered by informal caregivers or through other services (e.g., social adult day or adult day health care) do not count toward the 12-hour trigger. The MLTC plan should not refer the case to the IRP until it has submitted the enrollment to New York Medicaid Choice (NYMC). The IRP will make a recommendation concerning the ability of the individual to be served safely in the home. The MLTC plan is expected to consider the recommendation, but is not required to follow it, when finalizing the POC and service authorization.

The IRP is expected to finalize its recommendation within one week of assignment. A delay in the IRP does not extend the deadline for the plan to authorize services. If the IRP recommendation is late, the plan should authorize services under a temporary POC.

The regulations and related guidance documents include a process for addressing material discrepancies – mistakes and disputes over clinical judgments – between plans and the NYIA. This process, called the CHA Variance Request process, should be initiated within five business days of completion of the IA. If a material discrepancy in clinical judgment is raised, the NYIA must schedule a new CHA. The applicant may refuse a new CHA. The appropriate action for a plan, if the applicant refuses a new CHA, and the existing CHA is materially incorrect, is not clear.

The slides from the meeting are available here. A summary of the IA process and regulations is available here. MLTC policy guidance (MLTC Policy 22.01) provides additional information about the transition to the new process. Information for LDSSs regarding the transition of fee-for-service PCS and CDPAS cases is available in 22 OHIP ADM-01. A new Medicaid Update article on the IA process should be distributed this week.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8838