DOH Issues Personal Care / CDPAS Guidance for MLTC Plans

Last week, the Department of Health (DOH) issued MLTC Policy 16.06 to provide further guidance to Managed Long Term Care (MLTC) plans concerning appropriate reasons and notice language to be used when proposing to reduce or discontinue Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS). Of the reasons listed in regulation as appropriate causes for reducing or discontinuing PCS or CDPAS, the guidance focuses on two: (1) a change in the enrollee's medical or mental condition or social circumstances, and (2) a mistake in the previous authorization or reauthorization for these services.

In cases where the reduction is due to a change in the enrollee's condition or circumstance, the decision must be based on consideration of the individual's particular circumstances, and the notice to the enrollee must identify the specific change in the enrollee's condition or circumstance driving the reduction/discontinuation decision. The notice must also explicitly state why the service should be reduced or discontinued as a result of the change in the enrollee's condition.

The guidelines note that the more specificity the plan’s notice provides with regard to the specific change in the enrollee’s services, the reason for the change, and why the prior services are no longer needed, the better able the plan will be to defend its proposed reduction or discontinuation at any fair hearing, at which the plan bears the burden of proof to support its proposed action.

Plans must adhere to three guidelines when proposing to reduce or discontinue services based on a mistake that occurred in a previous assessment or reassessment:

• limit the definition of a "mistake" to a material error in a prior authorization or reauthorization;
• use the provision narrowly to address only service reduction or discontinuation directly tied to the error; and
• avoid using "mistake" as a reason in cases where an authorization was based on an accurate assessment but where a subsequent assessment suggests fewer hours are needed than previously thought. 

At the same time, DOH issued MLTC Policy 16.07 with guidance on the appropriate use of task-based assessment tools for PCS and CDPAS. While DOH has not approved any particular task-based assessment tool (i.e. client task sheet), MLTC plans may choose to utilize such tools, but must seek the Department's approval prior to their use or modification and must deploy them based on the following guidance:

• the tool must allow IADL and ADL time and frequency variations to accommodate an enrollee's individualized needs; 
• sufficient time must be included for safety monitoring;
• task-based assessment tools may not be used to authorize or reauthorize services for enrollees requiring 24-hour services;
• each plan (including those utilizing a task-based assessment tool) must document when and to what extent an enrollee needs IADL and ADL assistance, and whether the assistance can be scheduled or occurs unpredictably; and
• the tool may not be used to arbitrarily limit the hours of Level I housekeeping services for enrollees that require help with Level II tasks.

Contacts: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841 and Cheryl Udell, cudell@leadingageny.org, 518-867-8871