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DOH Specifies Personal Care and Consumer Directed Independent Assessment Regulations to Take Effect May 1st

The Department of Health (DOH) issued guidance on March 4th specifying the new personal care services (PCS) and consumer directed personal assistance services (CDPAS) regulations that will take effect on May 1, 2022 and notifying stakeholders that independent assessment provisions will preliminarily apply only to initial assessments – not reassessments. Other changes will be suspended until a later date to be announced with 60 days prior notice. LeadingAge NY is advocating for the repeal of the legislation establishing the independent assessment process as part of its advocacy on the State budget. We have also advocated for limiting the implementation of the independent assessment process to initial assessments.

The regulatory changes addressed in the March 4th guidance relate to the implementation of the expanded independent assessment process for PCS and CDPAS that was adopted as a result of the Medicaid Redesign Team (MRT) II process. This guidance follows an earlier directive, issued in November 2021, that specified regulations scheduled to take effect on Nov. 8, 2021. More information about the PCS and CDPAS regulations adopted in response to the MRT II process is available here and here.

Notably, the March 4th guidance phases in the independent assessment process by limiting it to initial assessments. The “initial assessment process” is defined as the community health assessment, the independent medical exam and practitioner’s order, and, where applicable, the independent review process conducted by the Independent Assessor (i.e., Maximus Health Services, Inc.) for those individuals newly seeking PCS/CDPAS and/or Managed Long Term Care (MLTC) eligibility. The independent assessment process for reassessments for adults 18 and over, as well as the independent assessment process for children ages 4-17, for both initial assessments and reassessments, will be implemented at later dates.

Among the significant changes to be implemented as of May 1st are:

  • The requirement that PCS and CDPAS be ordered by an independent practitioner under contract with DOH, and not the individual’s attending physician.
  • Prior to authorizing more than 12 hours of services per day on average, the local department of social services (LDSS) or Medicaid managed care organization (MMCO) must refer the case to the independent review panel (IRP) and must consider the recommendation of the IRP when finalizing the plan of care and in its decision to authorize such services.
  • The IRP composition and process and the requirement that the IRP provide a recommendation on whether the plan of care is "reasonable and appropriate to maintain the individual’s health and safety in his or her home." The recommendation may not specify the amount of services to be authorized.
  • The process for resolving mistakes and clinical disagreements in the assessment process between Maximus and MMCOs, and sanctions for failure to cooperate or abuse of the resolution process.
  • Alignment of the personal care immediate need process with the new assessment process. Under the new process, an individual must first provide to the LDSS a statement of need for PCS from a physician with direct knowledge of the applicant’s condition and an attestation of immediate need, before the individual is considered to have an immediate need.

New minimum needs eligibility requirements for PCS and CDPAS will be delayed until a later date, as will provisions governing reassessments and provisions requiring fiscal intermediaries to contract with DOH. The Department's guidance also indicates that it reserves the right to delay the actions scheduled to take effect on May 1st. DOH has launched a webpage dedicated to the Independent Assessment process that includes recordings of trainings held to date and has created an email address to receive questions concerning this process: independent.assessor@health.ny.gov.

Contact: Karen Lipson, klipson@leadingageny.org, or Meg Everett, meverett@leadingageny.org. Both can be reached at 518-867-8383.