On November 1, 2012, Consumer-Directed Personal Assistance Program (CDPAP) services were added to the benefit package for "mainstream" Medicaid managed care (MMC) plans. Most Medicaid recipients in New York State who do not also have Medicare, are already enrolled in these plans, or will be required to enroll soon, with only very limited exceptions or exclusions, described in this article. (See Map by County showing where MMC is mandatory). Also on November 1, 2012, CDPAP services must be covered by all Managed Long Term Care plans, which are now mandatory in New York City for dual eligibles (those who have Medicare and Medicaid) who need long-term community-based home care services.
See more in this news article.
See NYC HRA MICSA Alert 10/26/2012 on change in CDPAP services and managed care
The addition of CDPAP services to mainstream Medicaid managed care plans ("MMC") follows the addition in August 2011 of personal care (a/k/a home attendant services -- including housekeeping) services. In the past, people enrolled in mainstream MMC plans received most of their primary medical care through their managed care plan, but personal care/home attendant/CDPAP services were "carved out" of the managed care benefit package, so individuals applied for them through the local Medicaid offices (CASA offices in NYC). The home care providers billed Medicaid for the approved services on a fee-for-service basis, rather than under contract with the managed care plans. Now, the managed care plans will take over the role of assessing eligibility for and authorizing the number of hours of personal care and CDPAP services, and the plans will contract with and pay the personal care provider agencies and the CDPAP Fiscal Intermediaries out of their "capitation rate."
Note that this change only effects Medicaid beneficiaries for whom the following are true:
Receive Community Medicaid;
Do NOT receive Medicare (are not "dual eligibles");
Receive personal care services (aka "home attendant" or housekeeping) or Consumer-Directed Personal Assistance (CDPAP) services through their local district Medicaid program (or CASA in NYC) .
Are enrolled in a Medicaid Managed Care (aka "mainstream") plan.
Clients may not know if they are enrolled in one of these plans, since they would have been "auto-assigned" to a plan if they did not respond to an enrollment package they may have received by mail, asking them to choose a plan. SSI recipients who do not have Medicare became subject to "mandatory enrollment" in Medicaid managed care only in the last two years. To find out if your client is in a managed care plan, advocates in New York City, Long Island and about 17 upstate counties can call New York Medicaid Choice (Maximus) at 1-800-505-5678.
A statewide list of managed care plans, listing all counties that contract with each plan, is posted here Managed Care Plan Directory - Alphabetical by Plan. See also contact list showing just plans in NYC with phone numbers. On this webpage look under "Health Plans" heading to find plans in your county.
The August 2011 roll-out carving in personal care and housekeeping into the mainstream Medicaid Managed Care plans affected 5900 Medicaid recipients statewide, of which about 4100 are in New York City. The number affected by the Nov. 2012 addition of CDPAP services is not known.
On November 1, 2012 there should be no immediate change noticeable by CDPAP recipients who are in Mainstream Medicaid MMC plans. The MMC plans must contract with the existing CDPAP providers -- fiscal intermediaries -- in NYC and each county, as long as those fiscal intermediaries are willing to accept the current reimbursement rate paid by the county. The CDPAP fiscal intermediary is supposed to continue providing the same home care services that were authorized by the CASA/ DSS office. The only change is that the CDPAP provider agencies will have to bill the beneficiary's managed care plan for services provided after that date. The authorization period carries over, and the plans are required to continue paying the existing PCA provider to provide services for a 60-day transition period. Before the end of the 60 days, plans are expected to enter into contracts with PCA agencies, and this could cause some beneficiaries to have to switch agencies (and may lose their familiar aides, though the State has asked the plans to make an effort to keep continuity of aides). In addition, managed care plans may attempt to reduce hours on the next reauthorization; be on the alert for notices proposing changes to clients' care plans.
For more information about the change, read this guidance from the Dep't of Health and this Medicaid Update. See also this article.
Some of the managed care plans have posted some information on their websites -- e.g.
What to do if a CDPAP aide does not report to work after November 1st, or if there are other coverage problems --
Contact the CDPAP fiscal intermediary and find out their reason for not showing up. E.g. they've been told that they may not be paid for services they provide starting Nov. 1st. (List of the CDPAP "fiscal intermediaries" in NYS by county (updated May 2012). Or see CDPAANYS online list statewide.
Contact the Managed Care plan -- If the CDPAP fiscal intermediary or home care provider agency indicates that the problem is related to the managed care takakeover or carve-in of personal care or CDPAP services, call the member services general information number for the Medicaid recipient's managed care plan - use this statewide list or NYC list. Carefully record what they tell you:
No information or knowledge about personal care/CDPAP services
Personal care/CDPAP services are not included in the benefit package
Services are suspended or reduced pending re-assessment
Other
Register a formal complaint to the NYS Managed Care Complaint Line: 800-206-8125
Contact the NYSDOH Division of Managed Care:
Phone - (518) 473-1134
E-mail - e-mail to:
Send an e-mail summarizing the information you have collected to HLU@legal-aid.org. The Legal Aid Society, together with Selfhelp Community Sevices and the New York Legal Assistance Group are collecting information regarding the response of the home care agencies, the managed care plans and the state offices responsible for oversight. Please do not include clients' names or other personal identifying information without a release which should be attached to the e-mail. At this time, we are collecting these reports to monitor this process on behalf of a group of advocates. We cannot commit to represent any particular client on these issues, but will communicate with you to provide advice about the case and will keep you apprised of any developments we learn about regarding this issue.
For advocacy guidance on particular client cases, you can e-mail Selfhelp at legal@selfhelp.net. We can not promise to be able to respond, since we are short-staffed. If you do e-mail, please give detailed information as to what happened when you did all of the steps above (specify the name of the managed care plan, who you talked to and when, what was said), and specify the number of hours of personal care thta the client was receiving, for how long, client's date of birth, and what action has been taken.
If client lives in one of the 7 upstate counties in which Medicaid managed care is still voluntary, and not mandatory, she may be able to disenroll from the managed care plan and return to fee-for-service Medicaid.
AFTER THE INITIAL TRANSITION PERIOD, the managed care plans will reassess client's hours -
We expect they will threaten to reduce hours. Clients should be receiving written notice of a proposed reduction -- but may not. Whether or not they receive a written notice, here's what you can do:
1. File a complaint and/or appeal with the Medicaid managed care plan.
2. File a complaint with the State Department of Health Managed Care Complaint Line at (800) 206-8125.
3. Request a Fair Hearing. During a fair hearing, an independent state administrative law judge will hear your case. If you requested a Fair Hearing because your services were reduced or stopped, you may also be able to continue to receive these services while your fair hearing is being decided. This is called “aid continuing.”
4. On these cases, you can contact Selfhelp at legal@selfhelp.net or The Legal Aid Society at HLU@legal-aid.org or NYLAG at (212) 750-0800.