LeadingAge NY Meets with DOH Regarding Modifications to ALP to Comply with Federal Rule

LeadingAge NY met with Department of Health (DOH) leadership last week to discuss their conversations with the Centers for Medicare and Medicaid Services (CMS) regarding the Assisted Living Program (ALP) and compliance with the federal Home and Community-Based Services (HCBS) Settings Rule. While members are aware of certain aspects of the federal rule that we have been working on for years, there are aspects of the rule regarding conflict of interest that the State has been struggling to determine how the ALP would comply with. The Dear Administrator Letter (DAL) that was issued last summer spoke to the spirit of the rule without providing guidance on how providers can comply within the State’s statutory and regulatory framework. LeadingAge NY has been working to get clarification on this matter since that time.

The crux of the issue relates to the federal rule that requires that the entity who is a provider of Medicaid HCBS be separate from the entity that provides case management. Members who are part of a continuum may have seen this implemented in different ways in recent years. CMS is putting pressure on DOH to come up with a solution to get the Medicaid ALP to come into compliance with the federal rule. The Department is engaging LeadingAge NY and other associations to consider options and identify a solution that is least disruptive to ALPs and the people they serve.

LeadingAge NY will conduct a webinar with ALP members soon to provide more information on the federal rule, potential options, and gather feedback. Different constructs that the Department has considered are having Medicaid Managed Long Term Care (MLTC), health homes, or some other type of construct to offer independent case management; the Department is open to other ideas. LeadingAge NY asked the Department for clarity regarding what is meant by case management and whether it encompasses the day-to-day activities in a resident’s life or the larger coordination of Medicaid services. DOH indicates that the independent entity should be coordinating the care and planning for the recipient of ALP services and oversee the person-centered plan. We hope to have greater detail on this as we think further on what construct might make the most sense. Another issue we need more information on is the question of who does the assessment.

LeadingAge NY will hold a forum to provide background on these issues for members and obtain feedback from members to help inform our discussions with the Department. More information will be available shortly.

Background

Conflict-free case management (CFCM) and conflict of interest definitions are codified in four federal policy initiatives: the Balancing Incentive Program within the Affordable Care Act (ACA), Community First Choice (CFC) within the ACA, the HCBS Settings Final Rule (CMS 2249F), and the Older Americans Act Reauthorization Act.

LeadingAge NY provides this article to offer background on these issues and offers the following as background. CFCM requires that assessment and coordination of services be separate from the delivery of services, with the goal to limit any conscious or unconscious bias that a care manager or agency may have, and ultimately promote the older adult’s choice and independence. The different regulations surrounding CFCM and conflicts of interest require the restructuring of long-term services and supports (LTSS) delivery so that a single agency is not both assessing what services an individual needs and then providing those services to them. Separating the assessment of need and care plan development from the service provider can avoid conflicts in payment incentives and promote appropriate use of service. In Medicaid, states rely on trained assessors employed through state planning units (AAAs), local health departments, aging and disability agencies (ADRCs), or contracted vendors to conduct assessments, develop service plans, and provide case management. After the setting is chosen with the assessment of need and care plan, the service provider creates a site-specific plan of care.

Conclusion

LeadingAge NY will work with our ALP members to analyze the situation, consider options, and provide DOH with feedback on this critical issue. We encourage ALP member engagement on this issue.

Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828