COVID-19 Guidance for Medicaid Providers

Guidance for the Authorization of Community–Based, Long–Term Services and Supports Covered by Medicaid in response to COVID–19

  • Guidance is also available in Portable Document Format (PDF)

April 8, 2020

Re: Updated COVID–19 Guidance for the Authorization of Community Based Long– Term Services and Supports Covered by Medicaid

The New York State Department of Health (NYSDOH) is updating guidance issued on March 18, 2020: COVID–19 Guidance for the Authorization of Community Based Long–Term Services and Supports Covered by Medicaid ("COVID–19 LTSS Guidance"). This guidance is provided in response to the COVID–19 outbreak and the state disaster emergency declared by Executive Order No. 202 and shall remain in effect until subsequent notice from the NYSDOH which will be provided prior to or upon the expiration of such state disaster emergency. Updated information is underlined.

The New York State Department of Health (NYSDOH) is providing this guidance to Medicaid Managed Care Plans, Local Departments of Social Services (LDSS), and Consumer Directed Personal Assistance Program (CDPAP) pertaining to the current novel coronavirus (COVID–19) outbreak. The guidance applies to Medicaid covered services as described below when delivered through either Licensed Home Health Care Services Agencies or CDPAP. Topics include: (1) physician orders; (2) the initial Community Health Assessment; (3) Community Health Reassessments; (4) Annual Health Assessments for Personal Assistants; and (5) Facility–Based Assessments. Guidance provided herein should be shared by CDPAP Fiscal Intermediaries with Consumers and by Consumers with their Personal Assistants.

Background

The health and safety of the State"s health care workforce and our ability to provide and support patient care remain our priorities. Recently, community–wide transmission of COVID–19 has occurred in the United States (US), and the number of both Persons Under Investigation (PUIs) and confirmed cases are increasing in NYS. The situation with COVID–19 infections identified in the US continues to evolve and is very rapidly changing. It is imp ortant for all agencies, Medicaid Managed Care Plans, LDSS and Consumer Directed Personal Assistance Program (CDPAP) consumers keep apprised of current guidance by regularly visiting the Centers for Disease Control and Prevention (CDC) and NYSDOH websites, as well as the NYSDOH Health Commerce System (HCS), for the most up–to–date information for healthcare providers.

It is important to keep staff, enrollees, and Consumers updated as the situation changes and educate them about the disease, its signs and symptoms, and necessary infection control to protect themselves and the people they serve. NYSDOH distributes alerts and advisories on its website and, therefore, it is vital that all organizations maintain up–to– date contact with both the CDC and NYSDOH. Additionally, Medicaid Managed Care Plans, LDSS and CDPAP Consumers may wish to provide internal contact information for their staff, enrollees and Consumers, as applicable, to call with concerns, reports or questions.

Guidance

This Guidance applies all Medicaid Managed Care Plans, including Managed Long–Term Care Plans (Partial, Medicaid Advantage (MA) Medicaid Advantage Plus (MAP), and Program of All–Inclusive Care for the Elderly (PACE)), mainstream Medicaid Managed Care Plans, HIV Special Needs Plans, and Health and Recovery Plans.

  1. Physician Order: Initial authorizations for Personal Care Services (PCS) and Consumer Directed Personal Assistance Services (CDPAS) will continue to require a physician order. Pursuant to applicable state regulations, the physician"s order documents the medical examination that assess an individual"s needs for PCS or CDPAS and describes the patient"s medical condition and regimes and the patient"s need for assistance with personal services tasks. Based on this information, the physician must certify as part of the order that the patient is able be cared for at home. To promote compliance with CDC and NYSDOH guidance and avoid unnecessary exposure to COVID–19, effective immediately, and until further notice is provided by NYSDOH, the ordering physician is encouraged to use the telephone or permitted telehealth modalities in connection with completion of the required physician order. Physicians should consult with applicable provisions of NYSDOH"s recently issued special guidance on the use of telehealth for a description of permitted telehealth modalities.

    This means the physician may complete the medical examination through telephonic means. The physician"s order form (DOH–4359 or HCSP–M11Q) continues to be required, however, a Community Health Assessment (CHA) may be initiated upon receiving a verbal order from the physician. The "CHA" is the assessment that is housed in the Uniform Assessment System (UAS–NY) and is sometimes referred to as the "UAS". The physician is required to transmit the physician"s order form to the Plan or the LDSS within 120 days of the date the verbal order is issued. The Plan or LDSS must document the date the physician provided the verbal order in the member"s care plan.
  2. Community Health Assessments: Initial authorizations for PCS, CDPAS, and other community based long term services and supports (CBLTSS) (i.e., nursing services in the home, therapies in the home, home health aide services, adult day health care, and private duty nursing) and requests for changes in service authorizations, will continue to require a Community Health Assessment (CHA). To promote compliance with CDC and NYSDOH guidance and avoid unnecessary exposure to COVID–19, effective immediately, and until further notice is provided by NYSDOH, registered nurses may conduct the CHA by telephone or permitted telehealth modalities, as described in the applicable provisions of the Telehealth Guidance. During this time period, CHAs conducted by telephone or telehealth, which would otherwise require a face–to–face assessment to be fully completed, may be used to develop an initial plan of care for the recipient and to authorize necessary CBLTSS, both through fee–for– service and Medicaid managed care.

    Notwithstanding the ability to conduct a CHA by telephone or through telehealth, eligibility requirements and standards for services and Managed Long–Term Care (MLTC) plan enrollment are not being changed. To that end, a CHA conducted by telephonic or through telehealth, but that cannot be fully completed (e.g., the functional assessment) may not be used to determine initial eligibility for members to enroll in MLTC plans. Until such time as the CHA may be fully completed, the member"s LDSS will develop and monitor the plan of care. Additionally, this guidance does not preclude completion of a full CHA and enrollment in an MLTC if consistent with CDC and NYSDOH guidelines. For individuals already enrolled or newly enrolled in a Mainstream, HIV–SNP or HARP Medicaid Managed Care plan, the member"s plan will remain responsible for completing the CHA and monitoring the plan of care.

    A Partially Completed CHA is a CHA which cannot be fully completed because not enough information can be obtained by using telephonic or telehealth to sign and finalize the CHA in the UAS–NY. As indicated above, a Partially Completed CHA will not be used by the Conflict Free Evaluation and Enrollment Center (CFEEC) to determine eligibility for members to enroll in MLTC plans.

    Managed Long Term Care Plans may use the full CHA finished by CFEEC, conduct a face–to–face CHA if possible, or conduct a full CHA using telephonic or telehealth, to enroll and develop the member"s initial plan of care.

    The LDSS may use a Partially Completed CHA to develop an initial plan care for a member that cannot be enrolled in a Managed Long Term Care Plan.

    Hours of care that are initially authorized under a Partially Completed CHA will be authorized under a Temporary Plan of Care for up to 90 days without a notice of determination. If no hours are authorized based on a Partially Completed CHA, a notice of initial determination is still required. No later than 90 days after the date the hours of care are authorized and documented in the Temporary Plan of Care, a full CHA shall be completed, hours of care shall be authorized as determined necessary, and a notice of initial determination shall be issued. If a full CHA cannot be completed within 90 days after the date the hours of care are authorized, a follow up assessment by telephonic or through telehealth shall be conducted and notice of approval shall be issued on or before the 90th day to continue the hours of care under the Temporary Plan of Care, and services shall be approved and continued in this manner in 90–day intervals, until a full CHA is completed.

    Changes in hours of care (increases or decreases) that are authorized under a Partially Completed CHA will be authorized under a Temporary Plan of Care for up to 90 days without a notice of determination. No later than 90 days after the date the change in hours is authorized and documented in the Temporary Plan of Care, a full CHA shall be completed, hours of care shall be authorized as determined necessary, and a notice of determination shall be issued. If a full CHA cannot be completed within 90 days after the date the hours of care are authorized, a follow up assessment by telephonic or through telehealth shall be conducted and a notice of approval shall be issued on or before the 90th day to continue the hours of care under the Temporary Plan of Care, and services shall be approved and continued in this manner in 90–day intervals, until a full CHA is completed. Requirements for a physician"s order for changes in hours of care remain unchanged for LDSS and Plans, however, such order may be provided using the processes described above.

    Assessors who are conducting CHAs using the telephone or telehealth methods may consult with, and use information, provided by a family member or designated representative or individual who is physically in the home during the time the CHA is conducted, to perform the CHA.

    In addition, in Section A: Intake/Initial History of the CHA, assessors are instructed to answer the "Reason for Assessment" question as "Other" and enter "Telephonic initial assessment COVID–19 protocol" in the comment box. If the Assessor used the assistance of an individual in physically present in the home to perform the CHA the assessor should also indicate in this comment box assistance provided by, for example, the member"s daughter.

    For members who are transferring from one Medicaid Managed Care Plan to another, or transferring from or to Fee–for–Service coverage, the member"s current CHA may be used develop a plan of care.
  3. Reassessments and Home Visit: Effective immediately, and until further notice, NYSDOH is suspending all required periodic re–assessments of CHAs through Medicaid managed care (including MLTC) or fee–for–service Medicaid. In addition, the six–month in–person care management home visit requirement is also suspended. CHAs and in–person care management home visits otherwise due, but not conducted under this suspension should be noted in the plan of care and care management records for audit purposes.
  4. This suspension of the reassessment process applies to CHA reassessments required for enrollees in Managed Long Term Care Plans, and members receiving personal care services through an agency, and members in the Consumer Directed Personal Assistance Program (CDPAP) through a Medicaid Managed Care Plan or Medicaid Fee for Service. As part of the reassessment process, where there is no change in service hours, the current requirements for LDSS and Plans for a physician"s order is also suspended. Where such assessments are not conducted due to this suspension, the LDSS and Plan shall extend authorizations for the current level and type of services for 90 days.
  5. Personal Assistant Annual Assessments. Effective immediately, and until further notice, to ensure continuity of care for individuals receiving PCS through CDPAP, NYSDOH is suspending the annual renewal of the health assessment, immunizations and TB test required for personal assistants providing services to Consumers in CDPAP. This suspension does not apply to new personal assistants. Renewals that do not occur as a result of this suspension should be documented in the employee"s record.
  6. Facility–Based Assessments. When scheduling the CHA with a skilled nursing facility or other health care facility, LDSS and Conflict–Free Evaluation and Enrollment Center (CFEEC) staff must rely on the guidance and direction of facility medical director as to whether it is medically necessary for the individual to have a CHA evaluation. This guidance is consistent with Executive Order 202.1, which states only medically necessary visits will be allowed at skilled nursing facilities.
Guidance on Home Care Services and Close or Proximate Contacts

To help protect consumers and personal assistants, attached are two NYSDOH COVID–19 guidance documents related to home care services and close or proximate contact of a confirmed or suspected case of COVID–19. The links to those guidance documents are provided below:

Instructions for provider personnel who are at risk of being a Person Under Investigation (PUI)

Staff are exposed to the general community each day and could become infected with an acute respiratory illness (e.g. COVID–19, influenza, respiratory syncytial virus (RSV)), if community transmission of that illness is occurring. Providers should ensure they have a policy in place to speak with staff prior to them conducting face–to–face visits with enrolled members in order to screen the staff for symptoms or contacts that might have put them at risk. It is important that providers strictly enforce their illness and sick leave policies. Staff showing symptoms of illness should not be permitted to remain at work or visit members and should not return to work until completely recovered.

Staff who have been potentially exposed to someone with confirmed COVID–19, or to someone who is a person under investigation (PUI) for COVID–19, might be placed under movement restrictions by public health officials, based on exposure risk for having contracted COVID–19 and any presenting symptoms.

If a staff person is found to be ill upon screening, the agency should send the person home and suggest that they contact their primary care physician immediately or refer them to immediate medical care, if indicated.

Where can I direct my questions about COVID–19?

Questions can be directed to the following email address: icp@health.ny.gov; or to the toll–free call center at 888–364–3065.

Your diligence in implementing appropriate measures for COVID–19 preparedness is appreciated.

Where can I direct my questions about this guidance?

Please send any questions relating to this guidance to MLTCinfo@health.ny.gov.

Your diligence in implementing appropriate measures for COVID–19 preparedness is appreciated.

Jonathan Bick
Director
Division of Health Plan Contracting and Oversight
Office of Health Insurance Programs

Lana I. Earle
Director
Division of Long Term Care
Office of Health Insurance Programs