MLTC Independent Assessment Policy Provides Details on May 16th Launch

A new policy released last week by the Department of Health (DOH) describes in detail the procedures that will be followed, beginning May 16, 2022, for independent assessments of eligibility for Medicaid personal care services (PCS), Consumer Directed Personal Assistance Services (CDPAS), and Managed Long Term Care (MLTC) enrollment. The Independent Assessment (IA) process will replace the Conflict-Free Evaluation and Enrollment Center (CFEEC). Neither the new policy nor the IA process applies to Programs of All-Inclusive Care for the Elderly (PACE programs).

The following are some key highlights of the new policy, MLTC 22.01. Members are encouraged to read the policy in its entirety.

Transition to IA on May 16^th

The new policy details the following process for CFEEC assessment requests initiated prior to May 16^th:

Assessments that were scheduled under the prior process but take place on or after May 16^th will be conducted under the prior rules. The MLTC plan would conduct another assessment for plan of care (POC) purposes. The beneficiary would be responsible for obtaining a physician order for services.
MLTC plans are encouraged to use these "CFEEC" assessments as the basis for POC and service authorizations.

CFEEC assessments will be valid for 12 months as of May 16^th.

The New York Independent Assessor (NYIA) Process

The NYIA will schedule both a community health assessment (CHA) and a Clinical Appointment with the Independent Practitioner Panel (IPP) for individuals whose financial eligibility for Medicaid has been approved. The IPP clinician will issue the Practitioner Order (PO), eliminating the need for the beneficiary to obtain one from their own physician. Both the CHA and Clinical Appointment must be completed within 14 days of contact with the NYIA.

Upon completion of both the CHA and the PO, the individual will receive an NYIA Notice indicating their eligibility for MLTC enrollment and whether their health condition is stable to receive PCS and/or CDPAS in their home. If qualified for enrollment, the notice provided by the NYIA to the individual will direct the individual to contact the NYIA for information about available MLTC plans.

The NYIA CHA and the PO are to be used to develop the POC and authorize services. Notably, the policy provides that if the NYIA has conducted the CHA and Clinical Appointment, "the MLTC plan shall not conduct its own CHA but use the NYIA CHA and PO to inform its POC development."

The policy is unclear with respect to individuals who are not "medically stable." The policy states both that: (i) if the IPP determines that an individual is not medically stable to receive PCS and/or CDPAS, then the MLTC plan may not authorize PCS and/or CDPAS; and (ii) medically unstable individuals may still qualify for MLTC enrollment. It further states: "If a medically unstable individual is qualified and seeks MLTC enrollment, the MLTC plan will review the CHA and PO and evaluate if other Community Based Long Term Services and Supports (CBLTSS) may address the member’s demonstrated needs." It is possible that, under the policy, a beneficiary who is unstable may enroll in MLTC with additional clinical supports such as in-home skilled nursing or medical model adult day health care (ADHC). LeadingAge NY will be following up with the Department on questions concerning the policy.

Consistent with the regulations, changes in a member’s need for services unrelated to a significant change in condition (such as availability of informal supports) do not require CHA reassessment but do need to be documented in the POC, and the MLTC plan must consider and make any authorization changes.

Independent Review Panel

When an MLTC plan proposes to authorize more than 12 hours of services per day on average, the MLTC plan must refer the case to the NYIA Independent Review Panel (IRP). The MLTC plan should submit the IRP review request once the applicant has agreed to the proposed POC and the MLTC plan has submitted the enrollment to NY Medicaid Choice. The IRP is expected to finalize their recommendation within one week of assignment. The 12-hour trigger is determined by PCS and CDPAS hours only. Hours covered by voluntary informal assistance, or other services or programs (e.g., ADHC), do not count toward the threshold.

The IRP makes a recommendation as to whether the proposed POC is adequate and reasonable to ensure the individual’s health and safety in the home. This review is expected to primarily be a review of records, although the IRP may speak to or evaluate the individual through a telehealth modality or speak to the individual’s primary care practitioner and/or designated representative.

An IRP review is not required if the member:

is already in receipt of more than 12 hours a day, on average, of PCS and/or CDPAS as of the start date of the IRP;
has had an IRP review, and services are maintained at this higher level of care through subsequent proposed POCs regardless of whether proposed by the current plan, new plan, or local department of social services (LDSS);
has authorized hours above 12 previously, and the hours are increased further – e.g., an increase from 16 to 24 hours.

MLTC Plan Responsibilities

MLTC plans will continue to be responsible for performing the following assessments, until further notice:

Routine annual reassessments for authorizing PCS and/or CDPAS.
Non-routine reassessments as necessary, including:
- Return from institutionalization assessments
- Significant change in condition assessments
- Assessments at the individual’s request
MLTC to MLTC plan transfer assessments where the last assessment was conducted by the first plan (the new plan would code this as an initial assessment). However, where the last CHA was completed by the NYIA and is still valid, the new plan should use the NYIA CHA and not conduct another CHA.

MLTC plans will be responsible for coordinating with the NYIA. The policy requires MLTC plans to coordinate with the NYIA to streamline the process for the MLTC plan applicant. This includes maintaining updated enrollment records in the Uniform Assessment System for New York (UAS-NY) so that future Reassessment Notices go out automatically from the NYIA when the NYIA begins reassessment activities. If the NYIA requests the MLTC plan to confirm or update a member’s record in the UAS-NY, the MLTC plan must respond within one business day and confirm or update the record within three business days.

MLTC plans will also be responsible for:

Authorizing PCS and/or CDPAS and other services that support the beneficiary's health and safety in the community.
Updating and documenting the POC at least every 12 months or more frequently if the enrollee’s condition changes, at the request of the enrollee, or as otherwise appropriate.
Developing and maintaining a process to permit an enrollee to request an updated POC if the enrollee’s situation has changed.
Contacting the informal caregiver identified by the NYIA during the assessment process or one identified by the MLTC plan through care planning activities to determine the availability of voluntary informal supports.

Mistakes and Clinical Disagreements

The policy includes a structured process, consistent with the regulations, for resolving disputes – either material mistakes or material clinical disagreements – between the NYIA and MLTC plans. When plans identify either a material mistake or a material clinical disagreement, they must submit a CHA Variance Form. The MLTC plan must inform the beneficiary that a new CHA may be conducted as a result of the dispute. If the individual refuses the new CHA, the MLTC plan must use the CHA on file in developing the POC and authorization. Upon receipt of the Variance Form, the NYIA will issue a corrected assessment or schedule a new assessment. If the NYIA decides to schedule a new assessment, it will complete the new CHA within 10 days of the date it receives the Variance Form.

Questions regarding the IA process may be submitted here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383