Fax authorization to opt out someone else 1-917-228-8601
ICAN - OMBUDSPROGRAM FOR FIDA & MLTC Phone: 844-614-8800
TTY Relay Service: 711 Website: icannys.org ican@cssny.org
Please see this new article for all news in 2017.
Conflict-Free Assessments by New York Medicaid Choice now good for 75 days, expanded from 60 days. See MLTC Policy 16.08: Conflict Free Evaluation and Enrollment Center (CFEEC) Update to Expiration of Evaluations, dated Dec. 16, 2016. After 75 days, "...a new evaluation will be required if the consumer does not select an MLTC plan but continues to seek [home care] ...This change only applies to the expiration of the consumer´s CFEEC evaluation and in no way impacts the MLTC plan´s assessment period. Should you have questions regarding this information, please email the following address: CF.Evaluation.Center@health.ny.gov"
We understand that DOH is not requiring Centers Plan or other MLTC Plans to which Centerlight members transition to provide a 90-Day Transition Period, which is a 90-day "freeze" after an involuntary transition to managed long term care, during which the new plan must continue the same services with the same providers that the consumer previously received. See this link. However, we are informed that the plans are making efforts to ensure continuity of providers and services. Also, if the new plan determines to reduce services from the amount previously provided by Centerlight, whether after 90 days or at any time, the plan may only do based on finding that that the member's condition improved or other circumstances changed, and after providing written notice detailing such changes, with the right to request a fair hearing and aid continuing. See next topic re new DOH MLTC Policy directives on notice. Advocates and consumers should monitor this transition and contact ICAN, the consumer ombudsprogram for MLTC and FIDA for information or assistance.
Task-based assessment tools cannot be used to establish inflexible or “one size fits all” limits on the amount of time that may be authorized ... or the frequency at which such tasks can be performed. Plans must conduct individualized assessments of each enrollee’s need for assistance with IADLs and ADLs. This means that plans must permit the assessments of time, as well as frequency, for completion of a task to deviate from the time, frequency, or other guidelines set forth in the tool whenever necessary to accommodate the enrollee’s individualized need for assistance.
When an enrollee requires safety monitoring, supervision or cognitive prompting to assure the safe completion of one or more IADLs or ADLs, the task-based assessment tool must reflect sufficient time for such safety monitoring, supervision or cognitive prompting for the performance of those particular IADLs or ADLs....
...Example of supervision and cognitive pairing A cognitively impaired enrollee may no longer be able to dress without someone to cue him or her on how to do so. In such cases, and others, assistance should include cognitive prompting along with supervision to ensure that the enrollee performs the task properly."
See more helpful guidance in the directive.
MLTC Policy 16.06: Guidance on Notices Proposing to Reduce or Discontinue Personal Care Services or Consumer Directed Personal Assistance Services
Clarifies that Plans may not claim that it made a "mistake" when it authorized more hours in a prior authorization, as a justification for reducing hours now, unless the MLTC is rectifying "a material error made in a previous authorization for a particular enrollee." "A MLTC plan must not implement a new task-based assessment tool that contains time or frequency guidelines for tasks that are lower than the time or frequency guidelines that were contained in the plan’s previous task-based assessment tool, and then reduce services to an individual or across-the-board on the basis that a 'mistake' occurred in the previous authorization."
If the Plan claims that the enrollee's medical condition improved, the "notice must identify the specific improvement in the enrollee’s medical condition and explain why the prior services should be reduced as a result of that change..."
Minimum Wage Increases for Personal Care and Consumer Directed Personal Assistance Program (CDPAP) - In 2017, new increases in the minimum wage for home care workers go into effect, as enacted in state law passed by the Governor and the legislature last year. However, Medicaid funds must be allocated to pay for the increased wages. The wage increases and the very survival of the CDPAP program were threatened when the State Dept. of Health announced that MLTC plans would receive a boost in reimbursement totaling $70 million across all plans to cover only the increases for traditional home care workers, not for CDPAP personal assistants. The CDPAP program is an increasingly popular program statewide, and its survival would be threatened if the "fiscal intermediaries" (agencies that administer CDPAP services) were required to pay the wage increases without enough Medicaid dollars. On Dec. 14th,2016, the Governor's office confirmed that the $70 million would fund wage increases for both types of home care services. Kudos to the Consumer Directed Personal Assistance Association (CDPAANYS), Center for Disability Rights, ADAPT, and other disability rights organizations for successful advocacy!
Guildnet notified the State Dept. of Health that it "will no longer enroll members in Nassau, Suffolk and Westchester counties, according to a letter its chief sent to the state Department of Health. Alan Morse, CEO of GuildNet, told the Cuomo administration the 'calamitous state of reimbursement' made it no longer feasible to operate because the program was incurring 'substantial deficits.'" See story reported in Politico dated Nov. 23, 2016.
According to public data on DOH website, Guildnet has 40% of all 5,577 Suffolk MLTC members, 30% of all 6,159 Nassau MLTC members, and 15% of all Westchester MLTC members. Guildnet ceasing new enrollments, especially in Long Island, will inevitably put pressure on other plans to fill the gap.
|
Suffolk
|
||
|
plan
|
enrollment
|
percentage
|
|
Guildnet
|
2,256
|
40%
|
|
Fidelis
|
654
|
12%
|
|
North Shore LIJ
|
574
|
10%
|
|
Agewell
|
566
|
10%
|
|
Aetna
|
508
|
9%
|
|
Elderplan
|
302
|
5%
|
|
ElderServe
|
258
|
5%
|
|
5 plans combined - Centerlight, VNS Choice, Wellcare, Integra, Extended
|
459
|
each 1 - 4 %
Total 9%
|
| TOTAL MLTC | 5,577 | 100% |
|
Nassau
|
||
|
plan
|
enrollment
|
percentage
|
|
Guildnet
|
1,861
|
30%
|
|
North Shore LIJ
|
1,323
|
21%
|
|
Agewell
|
727
|
12%
|
|
Fidelis
|
528
|
9%
|
|
Aetna
|
384
|
6%
|
|
VNS Choice
|
290
|
5%
|
|
Elderplan
|
279
|
5%
|
|
Healthfirst
|
223
|
4%
|
|
5 plans combined -Integra, Elderserve, Centerlight, Wellcare, Extended
|
544
|
each 1- 2%
Total 12%
|
| TOTAL MLTC | 6,159 | 100% |
Class action lawsuit filed by The Legal Aid Society, challenging the failure of MLTC plans run by Healthfirst (Senior Health Partners and Healthfirst Complete Care) to process requests for increases, and the arbitrary denial of requests for increases in hours where the requested care is medically necessary. The lawsuit, called Bucceri et al. v. Zucker (No. 16 CV 8274 S.D.N.Y.), is against the company that operates Healthfirst and the NYS Dept. of Health. See this article about the lawsuit. This is the third lawsuit that challenges certain patterns of practices of MLTC plans.
Caballero et al. v Zucker - Lawsuit brought by NYLAG against Healthfirst (including Senior Health Partners MLTC plan) challenging pattern of arbitrary reductions in hours without legally adequate notice or adequate justification for reducing hours that were previously determined to be medically necessary. Proof of a medical improvement or other change in circumstances is required in such cases. See info about case and July 20, 2016 New York Times article about case, Lives Upended by Disputed Cuts in Home-Health Care for Disabled Patients
Scofero v Zucker - Empire Justice Center filed this class action lawsuit against the New York State Department of Health (DOH) on behalf of elderly and disabled Medicaid beneficiaries in need of homecare services such as personal care aides. The lawsuit challenges the pattern of MLTC plans turning away individuals with serious conditions who require significant amounts of homecare services. The MLTC plans tell them that they won’t be able to offer the level of care they require, even though they are under contract with DOH to do so. As a result, many individuals throughout New York State are left in nursing homes or are at risk of institutionalization. According to the lawsuit, the failure of the state to provide these services to needy individuals violates both the federal Medicaid Act and the Americans with Disabilities Act.. Download Complaint here.
IMMEDIATE NEED - NYS Dept. of Health and NYC HRA issue new procedures to implement the expedite Immediate Need procedures for applying for Medicaid and personal care or CDPAP for those with Immediate Need for these services. See this article.
The new expedited fast-track procedure for applying for Medicaid and obtaining personal care or CDPAP services where there is an "Immediate Need" through the LDSS goes into effect. This procedure was required by a state law enacted to address the problem of delays in obtaining Medicaid and enrolling in an MLTC plan. See this article about the law and how to do these applications.
Medicaid Matters NY, a statewide coalition, along with the New York Chapter of the National Academy of Elder Law Attorneys, issued a report titled "Mis-Managed Care: Fair Hearing Decisions on Medicaid Home Care Reductions by Managed Long Term Care Plans," to shed light on the findings of an extensive study of fair hearing decisions on reductions of personal care and Consumer Directed Personal Assistance services hours by Managed Long Term Care (MLTC) plans. The study identified all fair hearing decisions posted online during a seven-month period ending December 31, 2015. Decisions are posted in an online fair hearing archive of the state Office of Temporary & Disability Assistance (OTDA). The report makes specific policy recommendations to address the need for better oversight and monitoring of plan activities. The report was featured in a story in the NYTimes on July 21, 2016.
See the MMNY press release on the report here. Download the report on the NY Times site or the MMNY site.
On February 4, 2016, the state Department of Health (DOH) announced that it will be advancing $22.8 million in state-share funds to MLTC plans, which must directly pass the funds through to home care agencies they contract with, to meet their initial obligations under the recent Federal Labor Standards Act (FLSA) rule to pay aides overtime pay and travel between clients. See more at this article by Home Care Association of NYS
Given that the Consumer-Directed Personal Assistance Association estimates that overtime costs for Consumer-Directed workers alone will cost $35 million in 2016-17, the announcement by the state is not likely to be adequate to fund the extra costs.
Four trade associations representing providers estimate that the cost of the proposed increase in the minimum wage to $15, which will affect home care aides and other health workers, are requesting $916 million in appropriations to fund the first 2 years of increased costs for hospitals, nursing homes, and home care agencies. See HCA web posting 2/4/16 and Letter to Governor Cuomo, dated Feb. 4, 2016.
The State Dept. of Health notified MLTC plans that they must comply with revised regulations that are used in assessing the need for Personal Care Services and CDPAP. In particular, these changes modify who is eligible for 24-hour care, specify requirements for the content of notices when plans deny or reduce services, and make other changes. For a full description of the changes for personal care, see this article. The changes governing CDPAP are similar, and the article on CDPAP will be updated soon.
MLTC Policy 15.09: Changes to the Regulations for Personal Care Services (PCS) and Consumer Directed Personal Assistance (CDPA) Notice of Adoption (PDF, 1.8MB)
In July 2015, NYS Dept. of Health issued GIS 15 MA/011 - Reminder of Expedited Authorization Process for Medicaid Recipients with Immediate Need for Personal Care Services -- PDF. This directive makes an important change for any adult who has Medicare who needs Medicaid home care. Before this directive was issued, the "front door" was closed to request Medicaid personal care services from the local Medicaid agency. Anyone who had Medicare had to apply for Medicaid at the local Medicaid agency, but then had to enroll in a Managed Long Term Care plan to get home care. This caused big delays, described more here. With this directive, the individual may submit a physician's order - known as an M11q in New York City (fill-in-able version) - to the local Medicaid office, which must authorize personal care services if there is an "immediate need" for these services. Also see Q-Tips for tips on how the physician can complete the M11q.
TIP: Though this directive says that the local Medicaid agency will only process a request for expedited home care once Medicaid is approved, you can still submit the physician's order/ M11q along with the Medicaid application. Include a cover letter that requests that the Medicaid application be expedited and explain why individual has an immediate need for services and cannot wait to enroll in an MLTC plan. For more information see this article.
December 2015 - HIP/EmblemHealth MLTC plan sent letters to its 1300 members on November 25, 2015 that it would no longer offer MLTC coverage as of January 1, 2015. The notice stated that unless members choose and enroll in another MLTC plan by December 18th, they will automatically be enrolled in Guildnet. Emblemhealth had the 5th smallest enrollment of the MLTC plans in NYC.
people who remained in the plan could face barriers in accessing services from a plan that was pulling out of that county.
As the policy is understood, members who switch plans are not entitled to the new plan continuing the same services they had received from HomeFirst, because it is considered a "voluntary" move. This is contrary to the usual 90 day "transition period" which anyone required to switch to MLTC is entitled to.
Given the small number of plans in these upstate counties, there are also concerns that the other plans lack the resources to serve all of the enrolllees who transferred.
October 13, 2015 - Home Care aides entitled to overtime pay if work over 40 hours/week, with special rules for live-in cases. This change arises from a change in the federal regulations implementing the Fair Labor Standards Act (FLSA), which for decades exempted home care workers from overtime requirements under a "companionship" exemption. These regulations were amended, and then upheld by a federal court when challenged. For aides whose employer assigns them to travel between two or more clients, their travel time for traveling from one client to another must be compensated and counts toward 40 hours.
NYS Dept. of Health has posted an FLSA informational letter and FAQ on: https://www.health.ny.gov/health_care/medicaid/redesign/fair_labor_standards_act.htm
MLTC plans must ensure that home care agencies pay overtime. The NYS Dept. of Health has estimated that overtime costs will increase average hourly rate by 34 cents/hour and is increasing monthly capitation (premium) paid to plans to allow for that increase.
Some organizations, such as the Consumer Directed Personal Assistance Association, are protesting using that average, saying that many of the 17,000 CDPAP users have high-hour plans of care and need to keep reliable longtime aides and pay them overtime – more often than traditional home care agencies. They fear that the State's payment increase is insufficient to bear this cost. See http://cdpaanys.org/
APPEALS - "Exhaustion" of Internal Appeal will no Longer be Required effective July 1, 2015. This means member can immediately request a Fair Hearing to challenge a proposed denial, reduction or termination of services. While one may still request an internal appeal, one can only receive AID CONTINUING by requesting a Fair Hearing. Read more about this change here.
Expansion of Conflict-Free Eligibility & Enrollment Center -- Now rolling out to final region (See chart). In these counties, MUST REQUEST Conflict-Free assessment by NY Medicaid Choice before you may enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350. See more here. CFEEC rolled out from Oct. 2014 in NYC and by June 2015 was in effect throughout the State.
| Region | Month | Counties |
|---|---|---|
| 1 | October 2014 | New York (Manhattan) & Bronx |
| 2 | November 2014 | Kings (Brooklyn), Queens, Nassau & Richmond (Staten Island) |
| 3 | February 2015 | Westchester & Suffolk |
| 4 | March 2015 | East Hudson (Columbia, Dutchess, Putnam), Catskill (Rockland, Orange, Ulster, Greene, Sullivan), Capital (Warren, Washington, Saratoga, Fulton, Montgomery, Schoharie, Schenectady, Albany, Rensselaer), & Other (Erie, Monroe, Onondaga) |
| 5 | April 2015 | Southern Tier (Tompkins, Cortland, Tioga, Broome, Chenango, Otsego, Delaware), Finger Lakes (Wayne, Ontario, Livingston, Cayuga, Steuben), & Western (Cattaraugus, Wyoming, Genesee, Orleans, Niagara) |
| 6 | May 2015 | Central (Oswego, Oneida, Herkimer, Madison) |
| 7 | June 2015 | Early June (Chautauqua, Chemung, Essex, Hamilton, Schuyler, Seneca, Yates) Late June (Allegany, St. Lawrence, Franklin, Clinton, Jefferson, Lewis) - Pending CMS Approval |
Source: NYS DOH Updated 2014-2015 MLTC Transition Timeline (PDF, 88KB) (MRT e-mails) NYS DOH Policy & Planning Monthly Updates (on file with EFLRP - contact eflrp@nylag.org)
| Month | New Schedule | "MLTC Announcement" letter sent | 60-day "Choice" letters sent | "Front door" closed - no new Personal Care applications at local Medicaid office |
|---|---|---|---|---|
| 9/2012 - 12/2013 |
NYC, Albany, Erie, Monroe, Nassau, Onondaga, Orange, Rockland, Suffolk, Westchester |
|||
| Jan 2014 | Columbia, Putnam, Sullivan, Ulster | April 2014 | early May 2014 | May __ 2014 |
| June 2014 | Cayuga, Herkimer, Oneida, and Rensselaer | Week of May 23, 2014 | week of June 2, 2014 | May 30th |
| July 2014 | Greene, Saratoga, Schenectady, and Washington | Week of June 30th | Week of July 14 | July 7, 2014 |
| August 2014 | Dutchess, Montgomery, Broome, Fulton, Schoharie | Week of Aug. 29th | Week of Sept. 22nd | September 8, 2014 |
| September 2014 | Delaware, Warren | Sept. 15th | Oct. 1st | Sept. 22nd |
| October 2014 | Niagara, Madison, Oswego | Week of Oct. 27, 2014 | Oct. 20th | |
| November 2014 | Chenango, Cortland, Livingston, Ontario, Steuben, Tioga, Tompkins, Wayne | November 2014? | ||
| December 2014 | Genesee, Orleans, Otsego, Wyoming | Week of December 29, 2014 | Jan. 5, 2015 | |
| March 2015 | Cattaraugus | March 2015 | March 9, 2015 | |
| June 2015 |
Essex, Chemung, Chautauqua, Hamilton, Schuyler, Seneca, and Yates. |
June 2015 | June 19, 2015 (on and after 6/22/2015 must enroll in MLTC) | |
|
July 2015 |
Allegany, Clinton, Franklin, Jefferson, Lewis, St. Lawrence |
July 3, 2015 |
||
Conflict-Free Eligibility & Enrollment Center expands to more counties (see current chart in JUNE 2015 news) . In there counties, MUST REQUEST Conflict-Free assessment by NY Medicaid Choice before you may enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350. See more here.
More info on how FIDA will roll out -
SEE NYLAG Fact Sheet on FIDA with list of plans in NYC and Nassau County (Region I - first to roll out)
List of the 22 FIDA contracts is here published by Crain's NY. Until now, State only released list of 25 plans being considered for FIDA,but not the final list of 22 plans. Many plans are listed under different corporate names. NYLAG has compiled a list of the 22 plans showing which MLTC and Medicaid Advantage Plus plans they are affiliated with in each county in the Demonstration area - NYC, Long Island and Westchester. Note that some plans do not operate in every borough in NYC.
ROLL-OUT SCHEDULE - When MLTC recipients in Region I (NYC and Nassau) will receive the "announcement" letter starting December 2014 them telling about FIDA, and when will they be passively enrolled into FIDA plans - will be on a rolling basis depending on when they renew Medicaid for the year. Passive enrollment will happen over FOUR MONTHS beginning April 2015 Region II (Suffolk and Westchester) won't start receiving letters until March 2015.
NEWS that current NURSING HOME RESIDENTS will NOT be passively enrolled into FIDA plans! Only NEW people who first become PERMANENT NH residents in 2015 will be passively enrolled but not til August 2015. Only people who have approved for Institutional Medicaid after the 5-year lookback has been approved will be subject to passive enrollment. They will first receive letters giving them at least 90 days to select a FIDA plan on their own or to OPT OUT, and only at the end will be passively enrolled.
NOV.1st -- Conflict-Free Assessment required before MLTC enrollment in Brooklyn, Queens, Staten Island and Nassau County. See Sept. - Oct. 2014 news below. Must call NY Medicaid Choice to request assessment before you can enroll in an MLTC plan, in all of NYC and Nassau County. To schedule an evaluation, call 855-222-8350.
State issues new directive on Spousal Impoverishment protections, rescinding August 2014 directive and reinstating earlier directives. As a result, pooled trusts are again allowed for couples where one spouse is in MLTC. This is temporary - awaiting clarification from CMS. Suffolk County and any other county must retroactively re-budget every client, again allowing the pooled trust. See this article
On Sept. 30, 2014, DOH issued MLTC Policy 14.06: Implementation of the Conflict-Free Evaluation and Enrollment Center (CFEEC) that announces that the CFEEC is open in Manhattan and the Bronx. Anyone approved for Medicaid after Oct. 1, 2014 in those boroughs who is seeking Managed Long Term Care will need to first contact NEW YORK MEDICAID CHOICE and request a CFEEC assessment. If that assessment finds the person eligible for MLTC, then the person can enroll in an MLTC plan. To schedule an evaluation, call 855-222-8350.
SEE NEW YORK MEDICAID CHOICE WEBSITE ON CFEEC - http://nymedicaidchoice.com/ask/conflict-free-evaluation-and-enrollment-center
This is being implemented pursuant to #28 of the Special Terms and Conditions, which is CMS's approval of the State's 1115 waiver to implement mandatory MLTC, DOH has established a conflict-free assessment system for all voluntary enrollments into MLTC, MAP and PACE effective October 1, 2014.
Currently, private MLTC plans are responsible for determining eligibility for Medicaid-covered long-term services and supports (LTSS). This creates an intrinsic conflict of interest, because plans have a financial stake in avoiding high-cost members and attracting low-cost members. To partially reduce this conflict, DOH will prohibit MLTC plans themselves from enrolling new members. Instead, they will be required to refer prospective members to New York Medicaid Choice (aka Maximus), currently the enrollment broker for Medicaid managed care in NY.
Under this program, NY Medicaid Choice will establish a Conflict-Free Evaluation and Enrollment Center (CFEEC) to schedule and conduct initial assessment visits in the home or facility by a nurse (employed by or under contract with the CFEEC). Using the Uniform Assessment Tool, the CFEEC makes the determination of eligibility for Medicaid LTSS. If the CFEEC determines that the applicant is ineligible for Medicaid LTSS, it will send a written notice with appeal rights. If the CFEEC approves the applicant, then any MLTC, MAP, PACE or FIDA plan must accept the applicant's enrollment. If the plan disagrees with the CFEEC's determination of eligibility, it may pursue a dispute adjudication procedure via Maximus and DOH.
The CFEEC will be rolled out in phases:
Source: N.Y. Dep't of Health, FIDA and MLTC Policy and Planning Update Presentation (September 11, 2014, on file with NYLAG).
Will this delay enrollment into MLTC? Probably. MLTC plans may not accept an enrollment without confirmation from CFEEC that you are MLTC-eligible. That confirmation is valid for 60 days. The State FAQ (Q13) says the CFEEC assessment can be done while Medicaid application is pending, but since a Medicaid application can take more than 60 days - it can be risky. It is also unclear whether the consumer must only sign an MLTC plan enrollment form within 60 days of the CFEEC assessment, or must actually be enrolled in the plan by that date - the difference can be significant.
See new documents available from NYS DOH on the Conflict-Free Evaluation and Enrollment Center (CFEEC):
While we have no written confirmation of this fact, DOH staff have stated that the initiative to require all nursing home residents to enroll in Medicaid managed care plans has been once again postponed, this time to January 2015. Further updates may be posted here.
Greene, Saratoga, Schenectady, and Washington Counties -- The mailing of announcement notices to the fee for service population began during the week of June 30th, and the mailing of mandatory letters began during the week of July 14, 2014, giving 60-days to select a plan before being randomly assigned to an MLTC plan.
Beginning July 7, 2014, the "front door" is closed -- the County DSS no longer accepts applications for personal care or CDPAP. Applicants for those services, who have obtained Medicaid by applying at their local DSS, must select an MLTC plan, PACE or MAP plan -- and may enroll directly through the plan.. Contact New York Medicaid Choice 1-888-401-6582.
“The Office of Health Insurance Programs has not received approval from CMS to transition the Nursing Home benefit and population into managed care. We continue to negotiate the terms of this transition and therefore the implementation date has been extended to August 1, 2014. We will modify the current timeline reflected in the Nursing Home Policy Paper and will re-post it to the web. We apologize if the delay causes any disruption and will inform you when the approval is obtained.”
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