LeadingAge NY Comments on Conflict Free Assessment

Under MRT 90 (Special Terms and Conditions # 28), the Department of Health (DOH) is required to develop an independent and conflict free Long Term Care Services and Supports (LTSS) evaluation process. As a result, effective October 2014, DOH will begin implementing a Conflict- Free Evaluation and Enrollment Center (CFEEC) for individuals seeking Community-Based Long Term Care (CBLTC) services for more than 120 days.

Under the concept of Conflict Free Evaluation (CFE), the federal Centers for Medicare and Medicaid Services (CMS) have been looking for states to implement a “firewall” between the entity making the Medicaid managed care eligibility determination and the managed care plan responsible for the provision of the enrollees care and services. Under CFE, Managed Long Term Care Plans (MLTCPs) will no longer be permitted to enroll new individuals until the CFEEC has conducted an initial evaluation to determine CBLTC eligibility. DOH held a teleconference on the new CFEEC on Sept. 22 and the slide presentation and a recording, along with other materials, are available as follows:

DOH projects the statewide phase-in of the CFEEC by region as follows:

Region 1 – October 2014: New York (Manhattan) & Bronx

Region 2 – November 2014: Kings (Brooklyn), Queens, Nassau, & Richmond (Staten Island)

Region 3 – February 2015: Westchester & Suffolk

Region 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)

Region 5 – April 2015:

Southern Tier (Tompkins, Cortland, Tioga, Broome, Chenango, Otsego, Delaware)
Finger Lakes (Wayne, Ontario, Livingston, Seneca, Cayuga, Yates, Schuyler, Chemung, Steuben)
Western (Chautauqua, Cattaraugus, Allegany, Wyoming, Genesee, Orleans, Niagara)

Region 6 – May 2015:

Central (Jefferson, Oswego, Lewis, Oneida, Herkimer, Madison)
Northern (St. Lawrence, Franklin, Clinton, Essex, Hamilton)

DOH has been developing the concept of CFE for over a year, going back to the initial federal mandate under the Balancing Incentive Program (BIP). Under BIP, the State seeks to build upon current efforts to rebalance the delivery of Long Term Services and Supports (LTSS) and to promote enhanced consumer choice. According to DOH, the intent is to utilize the resources available through BIP to work toward streamlining eligibility processes, improve access and expanded LTSS for those in need. All of this is to be accomplished while ensuring that essential services are provided in the least restrictive setting. Complete information on BIP, including the concept of "no wrong door," is available on the DOH website by clicking here.

Some additional highlights from the Sept. 22 meeting worth noting include:

DOH will expand Maximus’ current role as enrollment broker under New York Medicaid Choice (NYMC) to perform CFEEC activities, including: Scheduling initial eligibility evaluations for people new to service seeking CBLTC; and, Staffing nurse evaluators to perform in-home evaluations (including hospitals, nursing homes) using the Uniform Assessment System-NY (UAS-NY).
The MLTCPs remain responsible for managing the individual’s care and developing the plan of care.
DOH anticipates a five to seven day turn around on Medicaid eligibility decisions. As noted above Maximus will use the UAS-NY as the standard assessment tool.
A dispute resolution process will be in place in cases where there is a discrepancy between the CFEEC eligibility determination and the MLTCP.
The CFEEC will evaluate consumer’s eligibility for one of the four MLTC products: 1.) Partially Capitated Plans, 2.) Program of All-Inclusive Care for the Elderly (PACE), 3.) Medicaid Advantage Plus (MAP), and 4.) Fully Integrated Duals Advantage (FIDA) (To be implemented January 2015).

Please see the above referenced DOH materials for more details.

Cabinets Join Forces!

Last year, our LeadingAge NY PACE/MLTC and Home and Community Based Services (HCBS) Cabinets worked together to provide DOH with guidance on the concept of Conflict Free Case Management (CFCM); our comments are available by clicking here.

Along with the PACE/MLTC and HCBS Cabinets, our Nursing Home Cabinet has joined the process and building on our prior work, developed our latest comments on the CFEEC, available by clicking here.

During this critical period of change, it is essential that our membership from across the spectrum of senior care and services work together to promote a constructive agenda. LeadingAge NY is grateful to our Cabinets for their joint guidance on this critical issue.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827