11 OLTC/ADM-1 - Long Term Home Health Care Program Waiver Renewal

To: Commissioners of Social Services

Subject: Long Term Home Health Care Program Waiver Renewal

Date: April 26, 2011

Suggested Distribution: Medicaid Staff, Home Care Services Staff, Legal Staff, Fair Hearing Staff, Long Term Home Health Care Program providers, AIDS Home Care Program providers

Contact Person: Any questions concerning this release should be directed to Laura Fiato, Bureau of Medicaid Waivers, by calling 518-474-5271

Attachments: Attachment I: Consumer Information Booklet, forms and instructions (PDF, 4KB, 1pg.), Attachment II: Waiver Services Definitions, Attachment III: LDSS and LTHHCP Agency Quality Assurance Responsibilities, Attachment IV: Reporting Forms and instructions (PDF, 25KB, 3pg.)

Filing References

  • Previous ADMs/INFs: 83 ADM-74, 85 ADM-26, 85 ADM-27, 90 ADM-25, 92 ADM-25, 02 OMM/ADM-4, 09 OLTC/ADM-01
  • Releases Cancelled:
  • Department Regulations: 18 NYCRR 505.21, 18 NYCRR Part 358, 10 NYCRR 763.5, 10 NYCRR 700.2 (b) (24)
  • Social Service Law & Other Leagal References: SSL 367-c, SSL 367-e, PHL 3616
  • Manual References: LTHHCP Reference Manual(6/06)
  • Miscellaneous References: "Health and Safety Standards for Certified Home Health Agencies", Health Facilities Series, 93-3 January 29, 1993

I. PURPOSE

This Administrative Directive (ADM) advises Local Departments of Social Services (LDSS) of the renewal of the 1915(c) Long Term Home Health Care Program (LTHHCP) Medicaid waiver granted by the federal Centers for Medicare and Medicaid Services (CMS) for the period September 1, 2010 through August 31, 2015.

The ADM consolidates previously issued Local Commissioner Memorandum (LCM) and General Information System (GIS) notices with regard to required quality assurance and data collection.

The ADM provides the following guidance and information about CMS authorized changes to the LTHHCP waiver program:

  • Quality assurance requirements for participant choice and service satisfaction (Page 4 and Attachment I);
  • Extended participant reassessment period from every 120 days to every 180 days (Page 5);
  • Enhancements to existing waiver services: Environmental Modification (Housing Improvement) and Medical Social Services (Page 9 and Attachment II);
  • Instructions related to use of three new waiver services: Home and Community Support Services; Community Transitional Services; and, Assistive Technology (Page 10 and Attachment II);
  • Procedural changes for spousal impoverishment budgeting for waiver participants (Page 15); and,
  • New data collection and analysis reporting requirements (Page 15 and Attachment IV).

II. BACKGROUND

The LTHHCP has served individuals since 1983, enabling the State to provide participants with a number of supportive services not otherwise available under the New York State Plan for Medicaid services. In response to consumer input obtained through a participant survey, the 2010 LTHHCP waiver renewal updated the original focus on care within the home to reflect the current federal and State emphasis on increased opportunities for informed choices for consumers, consumer independence, and involvement with care.

The LTHHCP waiver has three main objectives:

  • To prevent premature and/or unwanted institutionalization;
  • To enable institutionalized individuals to return to their community; and,
  • To provide access to cost effective coordinated care, case management, and monitoring of participants' health status.

CMS requires states to renew Home and Community Based Services (HCBS) waivers authorized under Section 1915c of the Federal Social Security Act every five years. Under the approved 2010 renewal, LTHHCP will continue to serve seniors and individuals with physical disabilities who: are medically eligible for nursing facility (NF) level of care; choose to remain at home; have assessed service needs that can be met safely in the home and community; and, have a service plan with Medicaid costs for services which fall within the participant's county of residence expenditure cap for nursing facility level of care.

Under the renewal, LTHHCP is available in all counties of New York State with the exception of: Livingston, Hamilton, Schoharie, Lewis, Essex, Chenango, and Schuyler Counties.

The renewal application specifically references the AIDS Home Care Program (AHCP) as a subset of LTHHCP. AHCP was instituted in 1992 to meet the challenge of the high incidence of AIDS in New York State. Certain LTHHCP agencies are approved by the CMS and the New York State Department of Health (NYSDOH) to provide the AHCP. These agencies provide the full complement of health, social, and environmental services provided by all LTHHCP agencies. (Refer to Required Action, Subsection D, Budgeting for information concerning a required change to budgeting rules for individuals in the AHCP on Page 14.)

Since January 2004 when the LTHHCP was last renewed, CMS has significantly increased quality assurance requirements for HCBS waivers that affect all aspects of waiver administration and service delivery. To comply with these new requirements, the LTHHCP waiver renewal application amended a range of waiver policies and procedures described below in Section III. Program Implications.

III. PROGRAM IMPLICATIONS

New York State Department of Health, LDSS and LTHHCP agency staff must implement new policies and procedures included in the application and reflected in this ADM to bring the waiver management into compliance with current Federal standards required for continued waiver authorization and Federal Financial Participation for waiver service costs.

The new/revised policies and procedures are to improve waiver quality care and accountability related to the following subjects: participant informed choice, involvement in care planning, and satisfaction with care and services; case management services by LTHHCP Registered Nurses (RN); extended reassessment time frames; new and/or revised waiver services; revised AIDS Home Care Program (AHCP) requirements; and, quality assurance processes.

IV. Required Action

The LTHHCP Reference Manual, first published June 2006, is currently under revision to reflect: changes in LTHHCP as a result of the waiver renewal; new quality assurance activities implemented since the 2006 publication of the current Manual; and, notice and fair hearing procedures for AHCP.

NOTE: Until the revised manual is released, the policy and procedural changes described in this ADM take precedence over those in the Manual.

A. Participant informed choice and satisfaction

For individuals who ask the LDSS for long term care services either directly or through referral, LDSS staff must provide objective information regarding the various home care options available to individuals and, as appropriate, their family and significant others. LDSS staff must advise all waiver applicants of choices among the following options:

  • Community based services or institutional care;
  • Available waiver programs for which the individual is potentially eligible;
  • Medicaid State Plan services; and,
  • Participating providers of such programs/services.

Those who wish to pursue waiver participation must be informed of their right to choose among appropriate waiver services as well as the provider of those services.

As noted in GIS 10 OLTC 001, LDSS staff must provide the "Long Term Home Health Care Program/AIDS Home Care Program Consumer Information Booklet" to all individuals seeking nursing home placement, applicants for and participants of LTHHCP/AHCP, and other interested individuals.

In alternate entry cases, the LTHHCP agency must inform potential participants of all long term care options, including use of general Medicare or Medicaid home care services, other Home and Community Based Services waivers and Managed Long Term Care. The LTHHCP agency must provide the potential participant with a copy of the Consumer Information Booklet and its attachments, and the Freedom of Choice form must be signed by both the consumer and the LTHHCP/AHCP representative.

The Consumer Information Booklet includes: consumer information about LTHHCP/AHCP; brief information on other Medicaid waiver programs; and, specific information regarding the Freedom of Choice, the Consumer Contact Information form, and the Consumer Satisfaction Survey.

The purpose of the Consumer Information Booklet and accompanying forms is to comply with CMS waiver quality assurance requirements by means of the following actions:

  • Provide pertinent information about the LTHHCP/AHCP;
  • Document applicant/participant choice of Medicaid home care services and/or other available Medicaid waiver programs;
  • Provide pertinent contact information to enrolled LTHHCP/AHCP participants; and,
  • Survey participant satisfaction as required for the LTHHCP/AHCP LDSS Quarterly Reports to NYSDOH.

The Booklet, with forms and instructions, is included in this ADM as Attachment I. The documents and forms must be reproduced by the LDSS. NYSDOH will notify LDSS staff when new forms and informational materials become available. Electronic documents will be posted to the NYSDOH Office of Health Insurance Program (OHIP) intranet site or through CentraPort.

LDSS staff play an integral part in the unbiased development of the individual's Plan of Care, thus assuring that the assessed needs are met and the participant's choice is considered. LDSS participation in the assessment and other processes mitigates potential inappropriate influence in provider selection.

If the LDSS staff does not agree with the proposed service plan for the individual, they must advocate for the individual with the LTHHCP agency and the physician as needed to adjust services to meet the individual's needs or choice. As an additional safeguard, the individual's physician must review and approve/sign the Plan of Care. The involvement of the LDSS and the individual's physician are important for purposes of the waiver complying with CMS expectations for participant choice.

B. Assessment and Reassessment

The purpose of the initial assessment and periodic reassessment to confirm and document that the applicant meets the waiver's level of care criteria remains critical to assure compliance with federally required eligibility criteria. Under the renewal, assessment and reassessments by the LDSS and LTHHCP agency must involve the applicant, the applicant's family if applicable, and a legally designated representative, or other individual(s) of the applicant's choice.

The waiver renewal implements legislation enacted in June 2010 to extend the reassessment time frame from every 120 days to every 180 days, or more frequently when a participant's service needs change. LDSS staff were instructed to phase-in the new policy effective September 1, 2010, as participants' existing 120 day authorizations expired and subsequent reassessment could then be authorized for 180 days.

The New York State Long Term Care Placement Form, Medical Assessment Abstract (DMS-1), will continue to be used for individuals age 18 and above.

The waiver renewal application includes, as approved by CMS, the use of certain LTHHCP alternative processes for admission to the waiver or eligibility for the waiver, including:

  • Continuation of the Alternate Entry process that allow LTHHCP agencies to initiate services in the home prior to LDSS authorization for waiver participation.
  • Continuation of permission for a physician to overridean individual's DMS-1 score by providing medical rationale to justify entry into the waiver or budgeting services at the higher Skilled Nursing Facility expenditure cap.

Documentation of the physician's justification to support such overrides, including any information obtained during reassessment, must be signed and dated by the physician and must be retained by both the LDSS and LTHHCP agency in the participant's case record.

C. Waiver Services

The Plan of Care includes the range of waiver and non waiver services necessary to allow the individual to remain in the community, and supports the individual's health, welfare, and personal goals. Each service, waiver or non-waiver, must be documented in the participant's Plan of Care, be cost-effective, and necessary to avoid institutionalization.

Note: Plan of Care continues to be the term used by the State for the LTHHCP; federally, the term "service plan" is also used for HCBS waivers. See section 6 on page 9 of this ADM, for description of new wavier services approved by CMS.

1. LTHHCP agency responsibilities

  • Provide or arrange for the provision of waiver and non- waiver services:

    The waiver renewal continues the policy that all waiver and non-waiver services are either provided or arranged for by the certified LTHHCP agency. The overall responsibility for coordination of all services, whether provided directly or through arrangements or sub-contracts, rests with the LTHHCP agency with responsibility for admitting the participant and implementing his/her Plan of Care.

  • Verification of qualified provider:

    LTHHCP agencies must have appropriate contracting policies and procedures. Each LTHHCP agency is responsible for verifying and assuring that all individuals or entities, with whom the LTHHCP agency has a contract for the delivery of one or more of the waiver services, are appropriately licensed, certified, and continue to meet the established qualifications for providing a specific LTHHCP service. Waiver service provider qualifications are provided in Attachment II Waiver Services Definitions.

2. Case Management

Under the renewal, CMS permits the State to continue to provide case management in the waiver as an administrative function of the LTHHCP agency. While not a discrete waiver service, it is a critical component to waiver eligibility and continued participation. To be eligible for the LTHHCP waiver, the individual must require service coordination, which includes but is not limited to, assessing the need for, coordinating, and monitoring all services needed to support the individual in the community.

In the LTHHCP, case management involves a comprehensive approach to the assessment and reassessment for all needed medical, psychosocial, and environmental services, and the coordination, delivery, and monitoring of all services in the individually approved Plan of Care that support the LTHHCP participant in the community within the individual's approved Plan of Care. This approach allows for services to be tailored to address all individual participant needs and to be well- coordinated, assuring an appropriate and cost-effective plan of care. LTHHCP agencies providing AHCP are able to tailor services to the needs of individuals with HIV/AIDS.

The LTHHCP agency provides case management to waiver participants through development and implementation of the Plan of Care. The LTHHCP agency RN must complete the DMS-1 form and applicable sections of the Home Assessment Abstract, identify necessary services, develop the Plan of Care, and obtain physician orders. The LTHHCP agency Registered Nurse (RN) is responsible for assuring that the Plan of Care is signed by the physician, implemented as intended, and modified when necessary. The RN coordinates, oversees and assures the delivery of all services in the Plan of Care; monitors all service providers, and supervises personal care and home health aides in the home.

For further information on the LDSS and LTHHCP agency roles in case management, refer to Attachment III LDSS and LTHHCP Agency Quality Assurance Responsibilities concerning federal quality assurance requirements for waiver programs.

3. Applicant/participant involvement in care planning

The applicant/participant has the right to choose any person to assist in the development of their Plan of Care, but must involve, as appropriate, the applicant, the applicant's family, legally designated representatives, and/or other individuals of the applicant's choice.

4. Choice of providers and services

Waiver applicants/participants have the right to choose from among qualified waiver service providers and to choose providers at any time, subject to availability. If a participant wishes to change LTHHCP agencies, and there are other available agencies serving the area, the LDSS must collaboratively work with the participant, the current LTHHCP agency, and the new LTHHCP agency to accomplish this change.

When developing the Plan of Care, the LTHHCP agency must inform the applicant/participant of the various available waiver services providers it has under subcontract. The applicant/participant has the right to choose from among available qualified providers.

The original model of the LTHHCP as a "nursing home without walls", under which the LTHHCP agency is vested with comprehensive responsibility for waiver services, remains a model preferable to many consumers as well as providers of the discrete waiver services. However, CMS required NYSDOH to develop a process by which qualified entities may enroll in LTHHCP as independent providers of waiver services. The waiver renewal now permits a waiver service provider to pursue direct enrollment with NYS Medicaid, if they do not wish to affiliate through subcontract with a LTHHCP agency. Procedures for direct enrollment will be developed by NYSDOH and, when available, shared with LDSS staff and providers.

5. New and/or modified waiver services

As Plans of Care for new applicants are developed or are reassessed for current participants, LDSS and LTHHCP agency staff must now consider the use of the new or modified services added under the renewal, and discuss options for change with participants and/or their representatives.

Definitions of all waiver services under the renewal are provided in Attachment II.

a. Modified waiver services:

  • Enhancement of Medical Social Services to include supportive counseling for individuals to help them adjust to living in the community with a disability.
  • Home Improvements service was renamed Environmental Modifications (E-Mod), reflecting the more current terminology and a broadening of the scope of service to include vehicle modifications.

    The following process is to be followed for authorizing E-Mods for the home or vehicle:

    • If the cost of the project is under $1,000, the LDSS may select a contractor (taking steps necessary to ensure reasonable pricing) and obtain a written bid from the selected contractor, which includes all terms and conditions of the project.
    • If the cost of the project is more than $1,000, a minimum of three written bids must be obtained. The LDSS may waive this requirement at its discretion (e.g. geographic limitations), documenting the reasons in the case record.
    • Bids of over $10,000 require architectural and engineering certification to ensure that the improvement conforms to NYS Fire and Building Code.

    E-Mods for the home include, but are not limited to:

    • Installation of wheelchair ramps;
    • Widening of doorways;
    • Modifications to permit independent use of a bathroom or facilitate bathroom use with assistance;
    • Stair glides; or,
    • Purchase of a backup generator for critical life sustaining medical equipment.

    E-Mods for the home are NOT to be used to:

    • Build any portion of new housing construction;
    • Build room extensions, or additional rooms or spaces, beyond the existing structure of a dwelling;
    • Renovate or build rooms for use of physical therapy equipment;
    • Purchase equipment such as therapeutic equipment or supplies, exercise equipment, televisions, video cassette recorders, personal computers, etc;
    • Purchase swimming pools, hot tubs, whirlpools, steam baths or saunas for either indoor or outdoor use;
    • Pave driveways;
    • Purchase central air conditioning, freestanding air conditioners or humidifiers;
    • Purchase and/or install elevators;
    • Purchase items that benefit members of the household other than the LTHHCP participant, or are of general utility for the residence; or,
    • Purchase service or maintenance contracts.

    Vehicle modifications may be made if the vehicle is the primary means of transportation for the waiver participant. Such modifications to assist with access into or out of a vehicle may include but not be limited to:

    • Portable ramp; or,
    • Swivel seat.

    E-Mods for a vehicle are not to be authorized, if:

    • The vehicle is not in good repair;
    • The vehicle is not the primary means of transportation for the participant;
    • The cost of the modification cannot be managed within the individual's expenditure cap.

b. New waiver services:

  • Addition of Community Transitional Services to assist with the cost of first-time moving expenses and/or establishing a household when transitioning from a nursing facility to the community. This service is not intended to assist in the move of an individual from one community residence to another and is limited to one time per waiver enrollment. Expenditure limitations are based on the individual's expenditure cap. This service may include such expenditures as:
    • Cost of moving furniture and other belongings from the nursing home to the new residence in the community;
    • Security deposits required to obtain a lease or utilities, exclusive of monthly rental fees;
    • Purchasing essential furnishings, such as a bed table and chair for meals, exclusive of such equipment for entertainment as TVs, computers, etc.; and,
    • Health and safety assurances, such as pest removal, allergen control or one time cleaning prior to occupancy.
  • Addition of Assistive Technology (AT) to incorporate the existing Personal Emergency Response System (PERS) waiver service and expand the scope of the service to take advantage of newer technologies. It is suggested that LTHHCP and LDSS staff develop a listing of potential Assistive Technology devices for NYSDOH consideration as service criteria is developed. LDSS staff and LTHHCP agencies will be notified by NYSDOH when additional AT devices are approved for use. As of the issuance of this ADM, Medication Dispensing machines (i.e., MD2) have not been approved for use.

    AT may include items such as:

    • Lift chair that allows the participant to rise independently to a standing position, thus reducing the need for personal assistance;
    • Devices to assist the hearing impaired, e.g. flashes a light when the door bell rings; or,
    • Sensor to activate an alarm when a cognitively impaired individual attempts to elope from the home.

    AT items allowable as State Plan Durable Medical Equipment are not covered or billable as a LTHHCP waiver service. In addition, any item covered by a third party payer, such as Medicare or private insurance, must be billed to that entity before billing Medicaid.

    Most LTHHCP agencies offer PERS as a waiver service and may continue to do so within the assistive technology service. PERS may be provided as a State Plan service in some instances.

    When LDSS staff review a LTHHCP Plan of Care and/or a request for authorization of PERS as a State Plan service, care must be taken to prevent duplication. Editing in eMedNY prevents billing for duplicate PERS claims for the same client in the same service period; proper coordination during Plan of Care development will minimizes disruption for the participant, as well as, LDSS and LTHHCP agency staff.

  • The addition of Home and Community Support Services (HCSS) combines personal care with oversight and supervision and cueing services, as well as assistance with activities of daily living (ADL) and/or instrumental activities of daily living (IADL) to support participants who have cognitive deficits and a discrete need for supervision and safety monitoring.

    In the development of the Plan of Care, LDSS and LTHHCP agency staff must identify whether the applicant or participant has unmet needs for discrete supervision and/or safety monitoring/cueing. If the individual also requires ADL and/or IADL assistance, the waiver Plan of Care should include HCSS to meet all those needs. Such services are to be billed by the LTHHCP agency using the appropriate HCSS rate codes.

    If there is no need for discrete supervision and/or safety monitoring/cueing, but there is an unmet need for ADL and/or IADL services, personal care services may be appropriately provided and billed by the LTHHCP agency.

6. Need for waiver services

In the past, participants in the LTHHCP waiver must be in need of case management and be eligible to receive one or more of the waiver services to assure health and welfare and provide support for community living. Under the LTHHCP renewal, an individual must be in need of and in receipt of case management and at least one other waiver service every 30 days to participate in the waiver. For purposes of this requirement, case management does not count as the one required waiver service, because it is an administrative function of the LTHHCP agency and not a discretely billable waiver service.

7. Reimbursement for services

As of the issuance of this ADM, the rate codes established for new waiver services include: Assistive Technology (AT) - rate code 3143; Community Transitional Services (CTS) - rate code 3144; and, Home and Community Support Services (HCSS) - rate code 3145.

Both AT and CTS rate codes will be added for use to all LTHHCP agencies' eMedNY rate file. The eMedNY rate file update for these services is anticipated for May 1, 2011. A letter is automatically sent by eMedNY to the LTHHCPs notifying them of the addition to their rate file. AT and CTS rate codes have a simplified claiming structure that allows the LTHHCP to submit one claim for the total LDSS authorized cost for the service. For example, if an item provided under AT has a total cost of $192.50, the claim submitted for the date of service will be for $192.50.

Rates for the new service of HCSS are currently being developed by DOH and must be approved by the Division of Budget before this service may be initiated. The HCSS rate is to be initially equated to the ceiling rate for the PCA Respite hourly rate. LTHHCP agencies will receive their rates and rate codes for HCSS with their 2011 final rates. An effective date for use of HCSS is the date of release of the 2011 final rates which is anticipated in June 2011. Specific instructions for implementation of HCSS will be issued to LDSS staff and LTHHCP agencies at that time.

The existing Housing Improvement rate codes - 9998, 9995, or 9992, were retained for use with the expanded service of Environmental Modifications (E-mod) to claim for both housing modification and vehicle modification. The rate code claiming structure is being amended to allow for a simplified claiming process. Previously, the LTHHCP was required to submit multiple consecutive claims at $2.00/unit with a maximum of 99 units/day until the total cost of the home improvement was claimed. Under the new simplified claiming structure, the LTHHCP submits one claim for the total LDSS authorized cost for the home or vehicle modification. For example, if the E- mod has a total cost of $5,092.50, one claim is submitted on the date of service for the total cost of $5,092.50. This change is anticipated for May 1, 2011 and will occur in conjunction with the rate file update for AT and CTS.

The effective date for use of AT and CTS is anticipated for May 1, 2011. Claims with service dates prior to the effective date will be denied. The effective date for the change in claim processing for E-mods is also anticipated for May 1, 2011. Currently, Housing Improvements continue to be available and claims for housing improvements with service dates prior to the anticipated effective date for E-mod implementation must continue to be process at $2/unit. E-mods with service dates after the implementation effective date will be claimed at one hundred percent of the approved cost.

NOTE: E-mods related to vehicle modifications will be implemented with the effective date of AT, CTS and, the eMedNY claim processing changes.

D. LTHHCP Participant Monthly Budgeting

The State must continue to assure cost neutrality of the waiver. Generally, the rules under which the LDSS budgets services for an individual under the waiver remains unchanged:

  • The individual expenditure cap set by NYSDOH is equated to 75 percent of the average cost of nursing facility care in the individual's county of residence as updated for each State fiscal year;
  • Medicaid expenditures for LTHHCP services may be up to 100 percent of that expenditure cap for persons designated as special needs;
  • If the individual is a resident of an adult care facility (ACF), the expenditure cap is 50 percent of the average cost of nursing facility care to account for services provided by the ACF.

The 2010 waiver renewal includes a required change to budgeting rules for individuals in the AIDS Home Care Program (AHCP). Until this renewal, there was no stated limitation on the budget for services provided to individuals in AHCP. With the renewal, budgeting for AHCP participants must follow the same expenditure cap rules applicable to other LTHHCP participants. Consequently, effective with the issuance date of this ADM, monthly budgets must now be calculated for AHCP participants beginning with the individual's application for the program or upon the next reassessment.

Policies and procedures for calculation of a prospective or enrolled participant's service budget remain unchanged.

Staff must include Medicaid reimbursed services in the participant's monthly budget. Medicaid reimbursed services, including, but not limited to, adult day health care, medical transportation, durable medical equipment, clinic services, and Office of Mental Health Community Residence rehabilitative services, must be included in the monthly budget in addition to LTHHCP agency services.

LDSS and LTHHCP agencies must work together to address the individual participant's circumstances, if the services required during a given period cause his/her cost limit to be exceeded. Both paper credits and annualization of the budget are effective in addressing fluctuations in an individual's needs. In addition, LDSS and LTHHCP agency staff must also consider other means of maintaining the service budget within the limit, including: maximization of third party resources; increased use of informal supports including community social services and/or family; and service substitution.

For example, it may be possible to use the waiver service of moving assistance to relocate a participant closer to a family member; the family member is then able to provide informal support on a more frequent basis, which lowers the participant's budget for paid assistance. Alternatively, initiating attendance at adult day health care may be a more cost effective means of providing coordinated services; however, all services available through the adult day health care must be provided at the facility and not duplicated by services in the home by the LTHHCP agency. Each case is unique and requires discussion with the participant and the participant's supports about his/her options and choices.

If services can not be maintained within the budget after alternatives are considered, participants must be informed and referred to other options for care as necessary. This may include the range of existing State Plan home care services, other available 1915c waivers such as the Nursing Home Transition and Diversion waiver, and Managed Long Term Care.

E. Medicaid Financial Eligibility

Medicaid financial eligibility for participation in the LTHHC waiver is determined by the LDSS.

Effective September 1, 2010, CMS approved the Home and Community Based Services (HCBS) Expansion Program to allow continued use of spousal impoverishment budgeting for a married individual with a community spouse, who otherwise would be Medicaid eligible if institutionalized and spousal impoverishment eligibility and post- eligibility rules were used.

The Office of Health Insurance Programs will issue a separate ADM with complete implementation instructions for the use of spousal budgeting (household of one) and spousal impoverishment budgeting through the HCBS Expansion Program. Until such instruction is provided, current spousal impoverishment budgeting should be continued.

F. Quality Assurance

CMS has set more rigorous requirements for NYSDOH in terms of oversight and monitoring responsibilities for quality assurance (QA) and quality improvement with respect to the 1915c HCBS waiver programs. Compliance with CMS assurances is required as a condition of Federal waiver approval and Federal Financial Participation.

Each LDSS and LTHHCP agency plays a critical role in assuring quality under the waiver. Attachment III, of this ADM, summarizes the key responsibilities of LDSS and LTHHCP agencies in the waiver's comprehensive quality management program. The responsibilities are sorted using the six waiver assurances required by CMS of all 1915c HCBS waiver programs.

In addition to the longstanding NYSDOH surveillance activities of LTHHCP agencies, NYSDOH has implemented increased oversight activities of LDSS waiver administration, including an annual review of a statistically valid sample of LTHHCP participant case records and Medicaid claims for services.

To improve accountability and quality of care under the HCBS waivers, increased QA requirements for record keeping from the point of an individual's application through to service planning, delivery, and outcomes has been implemented. To meet these standards, NYSDOH developed processes for:

  • Ongoing tracking of timeliness of applicant LOC determinations and adherence to assessment and reassessment requirements of being conducted at least every 180 days.
  • Ongoing evaluation and reporting of waiver participants' satisfaction with services.
  • Ongoing reporting of concerns related to waiver provider practices that may lead to investigation and need for remediation.
  • Ongoing reporting by LDSS staff regarding identification of significant alleged occurrences of abuse, neglect, and/or exploitation and the resulting corrective actions.

To initiate improved tracking and reporting process, the Long Term Home Health Care Program (LTHHCP) DSS Quarterly Report was issued effective April 1, 2009 via GIS 09 OLTC/002. The data collected and reported by district staff in the Report is used by NYSDOH for monitoring and analyzing trends, and identifying quality improvement issues in compliance with CMS QA requirements. See Attachment IV for the Quarterly Report form and instructions for completion.

G. NOTICES OF DECISION (NOD)

The LDSS remains responsible for issuing notices of decision, also known as client notices, used under the LTHHCP waiver. This includes the recently developed AHCP notices distributed in 09 OLTC ADM 01.

Use of LTHHCP NOD forms is mandated. All LTHHCP and AHCP NOD forms are currently posted to the intranet Library of Official Documents for use. The forms are available for download at http://health.state.nyenet/revlibrary2.htm or from CentraPort, by selecting Medicaid from functional areas and then going to ADM listing.

V. SYSTEMS IMPLICATIONS

LDSS functions related to updating and maintaining systems files are critical to the effectiveness of the waiver, helping to facilitate participants' initial access to waiver services, and further continuity of care.

The Restricted Recipient Exception Code for LTHHCP waiver participants is 30 (R/E Code 30). Upon authorization for waiver participation, LDSS staff must enter this R/E code into the WMS system. Only upon the LDSS determination that the participant is no longer financially or programmatically eligible for participation will LDSS staff need to make any changes to this file.

VI. EFFECTIVE DATE

This ADM is effective April 1, 2011.

Long Term Home Health Care Program Waiver Services

Waiver Service Description Provider Qualifications
Assistive Technology

This service supplements the Medicaid State Plan Service of durable medical equipment and supplies. The Medicaid State Plan and all other sources must be explored and utilized before considering Assistive Technology.

An Assistive Technology device may include an item, piece of equipment, or product system, whether acquired commercially, modified, or customized, that is used to increase, maintain, or improve functional capabilities of waiver participants. Assistive Technology is a service that directly assists a waiver participant in the selection, acquisition, or use of an assistive technology device. This service will only be approved when the requested equipment and supplies improve or maintain the waiver participant's level of independence, ability to access needed supports and services in the community or the waiver participant's safety. Assistive technology includes the Personal Emergency Response Services (PERS) service which was previously included in the waiver and expands the types of devices covered.

Documentation in the plan of care must describe how the participant's expected use, purpose and intended place of use have been matched to features of the products requested to achieve the desired outcome in an efficient and cost effective manner.

The service provider is responsible for training the waiver participant, natural supports and paid staff who will be assisting the waiver participant in using the equipment or supplies.

 Depending on the type of item, assistive technology may be provided by a licensed pharmacy (registered as a pharmacy by the State Board of Pharmacy pursuant to Article 137 of the NYS Education Law), a provider of Personal Emergency Response Services contracted by the LDSS, durable medical equipment provider to supply assistive devices not covered by the State Plan.
Community Transitional Services (CTS)

Individually designed services intended to assist a waiver participant transition from a nursing home to living in the community. CTS is a one time service per waiver enrollment. If the waiver participant has been discontinued from the program and now is a resident of a nursing home, they can access this service again, if needed.

This service is only provided when the individual is transitioning from a nursing home. It must not be used to move the participant from his/her home in the community to another location in the community. The funding limits for this service are separate from the limits applied to Moving Assistance, and the two services must not be used at the same time in any approved Plan of Care.

This service includes: the cost of moving furniture and other belongings, purchase of certain essential items such as linen and dishes, security deposits, including broker's fees required to obtain a lease on an apartment or home; purchasing essential furnishings; set-up fees or deposits for utility or service access (e.g. telephone, electricity, heating); and health and safety assurances such as pest removal, allergen control or one time cleaning prior to occupancy.

The service must not be used to purchase diversional or recreational items, such as televisions, VCRs/DVDs, or music systems.

Persons employed or contracted with a LTHHCP to provide CTS must be a: Master of Social Work, Master of Psychology, Registered Physical Therapist (licensed by the NYS Education Department pursuant to Article 136 of the NYS Education Law), Registered Professional Nurse (licensed by the NYS Education Department pursuant to Article 139 of the NYS Education Law, Licensed Speech Pathologist (licensed by the NYS Education Department pursuant to Article 159 of the NYS Education Law) or Registered Occupational Therapist (licensed by the NYS Education Department pursuant to Article 156 of the NYS Education Law). Providers shall have, at a minimum, one (1) year of experience providing information, linkages and referral regarding community based services for individuals with disabilities and/or seniors.

Moving services are provided by a moving company appropriately licensed /certified by the NYS Department of Transportation.
Congregate and Home Delivered Meals An individually designed service which provides meals to participants who cannot prepare or obtain nutritionally adequate meals for themselves, or when the provision of such meals will decrease the need for more costly supports to provide in-home meal preparation. These meals will assist the participant to maintain a nutritious diet. They do not, however, constitute a full nutritional regimen. It must not to be used to replace the regular form of "board" associated with routine living in an Adult Care Facility. Individuals eligible for non-waiver nutritional services would access those services first. Facilities or agencies contracted by the LTHHCP to provide home-delivered or congregate meals must comply with 10 NYCRR Part 14 for Food Service Establishments.
Environmental Modifications (E-mods)

Internal and external physical adaptations to the home, which are necessary to assure the health, welfare, and safety of the waiver participant, enable the participant to function with greater independence in the home, and prevent institutionalization. E-mods may include: the installation of ramps and grab bars; widening of doorways; modifications of bathroom facilities and kitchen areas; removal of architectural barriers that restrict, impede, or impair the performance of daily living activities; installation of specialized electrical or plumbing systems to accommodate necessary medical equipment; or any other modification necessary to assure the waiver participant's health, welfare or safety.

E-mods do not include improvements which are of general utility to the home (e.g. carpeting, roof repair, central air conditioning), which are not medically needed or do not promote the waiver participant's independence in the home or community.

An E-mod may alter the basic configuration of the waiver participant's home if this

alternation is necessary to successfully complete the modification but do not add to the total square footage of the home.

Modifications must be provided where the participant lives. If a participant is moving to a new location which requires modifications, the modifications may be completed prior to the participant's move. If an eligible individual is residing in an institution at the time of application, the modifications may be completed no more than 30 days prior to the participant moving into the modified residence. All modifications must meet State and local building codes.

Modifications may also be made to a vehicle, if in good repair and it is the primary means of transportation for the participant. This vehicle may be owned by the participant; a family member who has consistent and on-going contact with the participant; or a non-relative who provides primary, long term support to the participant. These modifications will be approved when the vehicle is used to improve the participant's independence and inclusion in the

The LTHHCP agency must ensure that individual(s) working on the E-mods are appropriately qualified and/or licensed to comply with any State and local rules; all materials and products

used must also meet any

State or local construction requirements; and, providers must adhere to safety standards as addressed in Article 18 of the New York State Uniform Fire Prevention and Building Code Act as well as all local building codes.

community. Modifications do not include: adaptations of improvements to the vehicle that are of general utility, and are not of direct medical or remedial benefit to the individual; purchase or lease of a vehicle; regularly scheduled upkeep and maintenance of a vehicle except upkeep and maintenance of the modification.

All E-mods must be priorauthorized by the LDSS.
Home and Community Support Services (HCSS)

The combination of personal care services (ADLs) and (IADLs) with oversight/supervision services or oversight/supervision as a discrete service. HCSS is provided to a waiver participant who requires assistance with personal care services tasks and whose health and welfare in the community is at risk because oversight/supervision of the participant is required when no personal care task is being performed. Services will be complementary but not duplicative of other services.

HCSS are provided under the direction and supervision of a Registered Professional Nurse. The Registered Professional Nurse supervising the HCSS staff is responsible for developing a plan of care and for orienting the HCSS staff.

HCSS differ from the personal care services provided under the Medicaid State Plan in that oversight/supervision is not a discrete task for which personal care services are authorized.

HCSS staff must be at least 18 years old; be able to follow written and verbal instructions; and have the ability and skills necessary to meet the waiver participant's needs that will be addressed through this service. In addition, staff providing HCSS must meet all other requirements under Title 10 NYCRR for the provision of Personal Care Aide services.
Home Maintenance Services

These services include those household chores and services that are required to maintain a participant's home environment in a sanitary, safe, and viable manner. Home maintenance tasks/chores differ from those provided by personal care or home health aides. Environmental support functions in personal care includes such tasks as dusting and vacuuming rooms the patient uses, making and changing beds, or light cleaning of the kitchen, bedroom and bathroom. The nature of personal care is to provide those routine tasks necessary to maintain the participant's health and safety in the home while Home Maintenance tasks are those chores accomplished in only one instance or on an intermittent basis.

Chore services are provided on two levels:

  1. Light Chores - Services are provided when needed for the maintenance of the home environment. Programs utilize these services when other means of supplying such services are unavailable or more costly. This service is often an appropriate substitute for part or all of personal care services. May include (but are not limited to) tasks such as:
    • Cleaning and/or washing of windows, walls, and ceilings
    • Snow removal and/or yard work to maintain egress and access
    • Tacking down loose rugs and/or securing tiles
    • Cleaning of tile work in bath and/or kitchen
  2. Heavy-Duty Chores - Services are provided to prepare or restore a dwelling for the habitation of a participant. They are usually limited to one-time-only, intensive cleaning/chore efforts, except in extraordinary situations. Since these services are labor intensive and more costly than routine cleaning, they should be provided more than twice per year. May include (but are not limited to) tasks such as:
    • Scraping and/or cleaning of floor areas (including situations where the movement of heavy furniture and/or appliances is necessary in order to perform the cleaning task)
    • Cleaning of items within an individual's dwelling and/or removal of any item(s) that may threaten the home's sanitary, fire safety, or other safety conditions.
  3. Home Maintenance Tasks – Other - These include those essential services required for the maintenance of the participant's home and home environment but which are not suitable for setting specific rates because of the variety of case situations or individuals involved. Services must meet all local building and safety standards. Services might include (but are not limited to) tasks such as:
    • Unique tasks (such as maintenance of a leaky sink trap)
    • Other heavy-duty chore services (those for which rates may not be determined before provision)

All services in the category "Home Maintenance Tasks – Other" must be prior authorized by the LDSS.

 The LTHHCP agency must ensure that individual(s) providing services comply with any State and local rules, and must adhere to safety standards.
Medical Social Services (MSS) MSS is the assessment of social and environmental factors related to the participant's illness, need for care, response to treatment and adjustments to treatment; assessment of the relationship of the participant's medical and nursing requirements to his/her home situation, financial resources and availability of community resources; actions to obtain available community resources to assist in resolving the participant's problems; and counseling services. Such services shall include, but not be limited to: home visits to the individual, family, or both; visits preparatory to transfer of the individual to the community; and patient and family counseling, including personal, financial and other forms of counseling services. The service may also assist participants who are experiencing

significant problems in managing the emotional difficulties inherent in adjusting to a significant disability, integrating into the community, and on-going life in the community.

MSS is an individually designed service intended to assist waiver participants who are experiencing significant problems in managing the emotional difficulties inherent in adjusting to a significant disability, integrating into the community, and on-going life in the community. It is a counseling service provided to the waiver participant who is coping with altered abilities and skills, a revision of long term expectations or changes in roles in relation to significant others. It is available to waiver participants and/or anyone involved in an ongoing significant relationship with the waiver participant when the issue to be discussed relates directly to the waiver participant. There are times when it is appropriate to provide this service to the waiver participant in a family counseling or group counseling setting.

Medical Social Services is provided and arranged for by the LTHHCP agency to deal with a wide variety of mental, emotional, behavioral, and environmental conditions. Emotional disturbances, family difficulties, adjustment problems related to acute and chronic illnesses, alcohol and substance abuse, and social issues are typical of situations that are addressed by Medical Social Services. Such services also include assistance with problem solving to overcome difficulties with transportation in the community and caregiver turnover and/or absences.

 As staff of LTHHCP agency, direct employment, or contracted to provide medical social services, a qualified social worker means a person who holds a masters degree in social work after successfully completing a prescribed course of study at a graduate school of social work accredited by the Council on Social Work Education and the Education Department, and who is certified or licensed by the Education Department to practice social work in the State of New York.

When employed by an LTHHCP agency, such social worker must have had one year of social work experience in a health care setting. NYCRR Title 10 Section 700.2(b)(24)
Moving Assistance Services

Individually designed services intended to transport a participant's possessions and furnishings when the participant must be moved from an inadequate or unsafe housing situation to a viable environment which more adequately meets the participant's health and welfare needs and alleviates the risk of unwanted nursing home placement. Moving Assistance may also be utilized when the participant is moving to a location where more natural supports will be available, and thus allows the participant to remain in the community in a supportive environment

Moving Assistance does not include purchase of items such as security deposits, including broker's fees required to obtain a lease on an apartment or home; set-up fees or deposits for utility or service access (e.g. telephone, electricity, heating); and health and safety assurances such as pest removal, allergen control or cleaning prior to occupancy.

 The LTHHCP has the responsibility for assuring that the moving service is provided in a safe and efficient manner. Any moving company used must be appropriately licensed/certified by the NYS Department of Transportation.
Nutritional Counseling/Educational Services An individually designed service which provides an assessment of the participant's nutritional needs and food patterns; planning for the provision of food and drink appropriate for the waiver participant's conditions; the provision of nutrition education, and/or counseling to meet normal and therapeutic needs. In addition, these services may include assessment of nutritional status and food preferences; planning for the provision of appropriate dietary intake within the participant's home environment and cultural considerations; nutritional education regarding therapeutic diets as part of the development of a nutritional treatment plan; regular evaluation and revision of nutritional plans; and, the provision of in-service education to the participant, family, advocates, waiver and non-waiver staff as well as consultation on a participant's specific dietary problems. As staff of LTHHCP agency, direct employment, or contracted to provide nutritional counseling/education services must be licensed as a Registered Dietician pursuant to Article 157 of NYS Education Law or be registered as a Registered Nutritionist pursuant to Article 157 of the NYS Education Law.
Respiratory Therapy An individually designed service, specifically provided in the home, intended to provide preventive, maintenance, and rehabilitative airway-related techniques and procedures. Services include application of medical gases, humidity and aerosols; intermittent positive pressure; continuous artificial ventilation; administration of drugs through inhalation and related airway management; individual care; and instruction administered to the participant and natural supports. As staff of LTHHCP agency, direct employment, or contracted to provide Respiratory Therapy must be licensed and currently registered as a Respiratory Therapist pursuant to Article 164 of the NYS Education Law.
Respite Care

An individually designed service intended to provide relief to natural, non-paid supports who provide primary care and support to a waiver participant. The primary location for the provision of this service is in the waiver participant's home, or where appropriate, temporarily in an institutional setting. These services will be provided to family and other caregivers who ordinarily care for the individual, as temporary relief from these duties and are included in the physician-approved Plan of Care.

Respite may be provided outside of the participant's home, such as in the home of a relative or other individual's private residence. Room and board in these instances will not be claimed.

Respite also may be provided outside of the home in an institutional setting such as a hospital or a nursing facility. In these two institutional settings, room and board is included in the daily rate for reimbursement and is included in the claimed amount.

Providers of Respite must meet the same standards and qualifications as the direct care providers of nursing, home health aide, personal care, and housekeeping. If the services needed by the waiver participant exceed the type of care and support provided by the Home and Community Support Services, then other appropriate providers must be included in the plan for Respite and will be reimbursed separately from Respite.

Respite care can be provided on a 24 hour basis, but is limited to a total of 14 days (or 336 hours)/year. Any request for respite care in excess of this time period must be prior approved by the LDSS.

 Providers of respite must meet the same standards and qualifications as the direct care providers of nursing, home health aide, personal care, and housekeeping. Respite services in the home may only be provided by professional and paraprofessional staff (nurse, home health aide, personal care worker, housekeeper) trained and certified under NYS rules and regulations.

Institutional Respite may be provided by hospitals or nursing homes licensed under Article 28 of NYS Public Health Law.
Social Day Care

This service provides the opportunity for individual socialization activities, including educational, craft, recreational and group events. Such service may include hot meals, or other services that may be offered which are authorized in a Plan of Care approved by a physician. In some instances transportation between the individual's home and the location of the social day care may be included in the cost of the social day care service.

Acceptable social day care services may be developed and provided directly by the LTHHCP agency or made available through contract with community agencies such as senior service centers, adult homes, programs for the elderly approved by the New York State Office for the Aging, and activities programs provided by residential health care facilities approved under Article 28 of the New York State Public Health Law.

It is necessary that all buildings, premises, and equipment be safe and suitable for the comfort and use of the participant. They should be maintained in a state of good repair, with adequate sanitation facilities and must conform to all applicable laws. The requirements of all ordinances, rules, and regulations of all local, state, and federal authorities relative to the premises (including safety, fire, health, sanitation, and occupancy considerations) must be observed.

 Programs must comply with Title 9 Section 6654.20 NYSOFA Social Adult Day Care Regulations and, as appropriate, NYCRR Title 18 Part 492- Adult-Care Facilities Standards for Day Programs forNonresidents.
Social Day Care Transportation

Provides transportation between the participant's home and the social day care facilities. Social Day Care Transportation service is limited solely to the purpose of transporting LTHHCP participants to and from approved social day care programs as discussed under that service section.

All transportation to social day care must be prior authorized by the LDSS.

A LTHHCP agency subcontracts with a Social Day Care program and negotiates a cost for the service either with transportation included in the cost of the program or in addition to the program's cost. The rate payable through eMedNY for each LTHHCP agency is calculated based upon this agreement with the Social Day Care program. Since duplicate payment is not permitted under Medicaid, LTHHCP agencies must not bill separately for transportation to social day care if the service is included in the Social Day Care program rate; and, the LDSS must verify that duplication will not occur when it authorizes the plan of care.

 The LTHHCP agency must assure that transportation services are provided in accordance with the regulatory criteria specified by the New York State Departments of Transportation, Motor Vehicles, and Health as appropriate for the carrier, including Title 9 NYCRR Section 6654.20; NYS Transportation Law, Articles 4 and 7; NYS Vehicle and Traffic Law.

Long Term Home Health Care Program Waiver CMS Quality Assurances

CMS Quality Assurance LDSS Responsibilities LTHHCP Agency Responsibilities
I. The waiver must have an adequate and effective system to assure appropriate level of care determinations with ongoing, systemic oversight of the level of care determination process
  • An evaluation for level of care must be provided to all applicants for whom there is reasonable indication services may be needed in the future.
  • The level of care of enrolled participants must be reevaluated as frequently as specified in the approved waiver.
  • The process and instruments used to determine participant level of care must be applied appropriately and according to the description in the approved waiver application.
 The LDSS must:
  • Assure each applicant for whom there is reasonable indication services may be needed has had his/her need for nursing home level of care (LOC) assessed and, if accepted into the waiver, has that LOC reassessed at least every 180 days or more frequently if circumstances warrant.
  • Obtain physician's recommendation and level of care assessment (DMS-1) from the LTHHCP agency.
  • Review every LOC instrument, i.e., The Long Term Care Placement Form, Medical Assessment Abstract (DMS-1) submitted and completed by the licensed medical professional assessor to assure all sections are complete, the form is signed and dated appropriately, and all indicators are scored accurately.
  • Confer with the assessor to discuss and remediate all identified issues.
  • If agreement can not be reached, request review by the LDSS local professional director who will review the case and make the LOC determination.
  • Contact State waiver management staff for technical assistance if needed in resolving disputes.
  • Track and report timeliness of application processing information related to LOC assessments/determinations, using specifications provided by DOH.
 The LTHHCP agency must:
  • Have staff RN examine /interview/assess an applicant/participant in a face to face visit to complete the Long Term Care Placement Form, Medical Assessment Abstract (DMS-1) and sign it, attesting to the validity of the assessment. (Alternatively, this may be done by the applicant/participant's attending physician or a facility RN if the individual is hospitalized or residing in a nursing home.)
  • Forward the assessment to the LDSS in a timely manner and confer with the LDSS to discuss and remediate all identified issues, accepting the determination of the LDSS local professional director if agreement can not be reached with LDSS staff.
II. The waiver must maintain an effective system for reviewing the adequacy ofserviceplans for waiver participants.
  • Service plans must address all participants' assessed needs (including health and safety risk factors) and personal goals, either by waiver services or other means.
  • Service plan development must be monitored in accordance with policies and procedures.
  • Service plans must be updated/revised as set forth in the waiver application but, at minimum, at least annually or when warranted by changes in the participant's needs.
  • Services must be delivered in accordance with the service plan, including the type, scope, amount and frequency specified in the service plan.
  • Participants must be afforded choice between waiver services and institutional care and between/among waiver services and providers.
Note: Federal Medicaid waiver terminology uses "service plan;" in the LTHHCP waiver this is referred to as the "plan of care."		 The LDSS must: Plan of Care Development
  • Authorize initial home assessment.
  • Conduct an assessment of the home environment, the individual's psychosocial status and availability of support systems using the Home Assessment Abstract (HAA) tool which is used with the DMS-1/PPRI to provide a full assessment of the individual's strengths and needs. This is done in cooperation with the LTHHCP agency.
  • Use the full assessment to develop a Plan of Care which includes the range of services, both waiver and non-waiver, necessary to allow the individual to remain in the community, addressing his/her health, welfare and personal goals. This is done with the LTHHCP.
  • Identify risk factors and safety considerations; incorporating interventions into the Plan of Care with consideration of the participant's assessed preferences.
  • Include necessary back-up arrangements such as availability and use of family members or other informal supports to assist the participant.
  • Include the applicant/participant, his/her family, significant others, legally designated representative(s) and/or other representatives of his/her choosing in Plan of Care development.
  • Maintains a positive relationship with the individual and family by clearly identifying the names and telephone numbers and by explaining the responsibility of the LDSS personnel who will be contacting the individual and supporting the family's involvement in the program.
  • If disagreements occur in Plan of Care development, confer with the LTHHCP agency for remediation; if agreement can not be reached refer the case for review to the local professional director who will determine appropriate adjustments.
  • Review the proposed Plan of Care and compare it to the physician's orders to ensure all needs are met and services provided.
  • Investigate all unmet needs and, if found, contact the LTHHCP agency for discussion and resolution.
  • Develop the individual's budget based on the agreed upon the Summary of Service Requirements; annualize the individual's budget, as appropriate, to effectively address fluctuations in his/her service needs. Gives final approval on budgets proposed by the LTHHCP provider.
  • Maintains and authorizes use of "paper credits" for individual.
  • Approve for waiver participation each individual whose needs, goals, health and welfare can be served within his/her individual limit. Authorize provision of LTHHCP services and participation; and notify provider concerning admission dates.
  • Assure the individual is referred to other appropriate resources if the Plan of Care can not meet the individual's needs to assure health and safety.
Plan of Care Update/Revision
  • Repeat the Plan of Care process at least every 180 days or more frequently when circumstances warrant. Review all subsequent Plans of Care for completeness and timeliness.
  • Approve of any change in the Summary of Service Requirements arising from changes in the individual's health status, and agree or disagree with any proposed changes to the services specified in the Plan of Care.
  • Use the range of available options to continue to meet the individual's service needs, e.g. use of paper credits, budget annualization, use of appropriate alternative waiver/non-waiver services, maximization of third party resources, increased use of informal supports, including other community resources. Also, coordinate (with provider RN) any changes in services with the family/caregivers to help them understand the changes.
  • Seek appropriate alternatives when decreasing services or referring to alternative community based services or for institutionalization; provide comprehensive information to any agency to which individual referred.
  • Send notice to the individual/family regarding: proposed discontinuance of the individual's participation in the LTHHCP; proposed reduction, denial, discontinuance of service contrary to treating physician orders or when level of budget cap changes from SNF to HRF.
Service Delivery
  • Assist LTHHCP provider in arranging for delivery of services not available from the LTHHCP (adult protection, legal counseling, recreational therapy, financial counseling, friendly visitors and/or telephone reassurance) as well as in making referrals to LDSS programs (such as Food Stamps, HJEP, and PA).
  • Maintain regular contact with the waiver participant to discuss the delivery of services in the approved initial or revised Plan of Care.
Participant Choice
  • Offer all potential waiver participants informed choice between community-based services and institutional care.
  • For those choosing community-based care, discuss and offer choice of MA waiver programs and non-waiver services/programs such as the Personal Care Services Program or Managed Long Term Care.
  • Notify all potential individuals or their families about availability of LTHHCP services (verbal and written notification).
  • Offer choice of providers of such services/programs from among qualified/participating providers.
  • Provide applicants/participants with the LTHHCP Consumer Information Packet, customized to include a list of LTHHCP agencies serving the county.
 The LTHHCP agency must: Plan of Care Development
  • Conduct a DMS-1 assessment or obtain one from the medical professional who conducted the assessment (as noted above under the first assurance) to be used with the HAA tool completed with the LDSS to provide a full assessment of the individual's strengths and needs.
  • Use the full assessment to develop a Plan of Care which includes the range of services, both waiver and non- waiver, necessary to allow the individual to remain in the community, addressing his/her health, welfare and personal goals. This is done with the LDSS.
  • Identify risk factors and safety considerations, incorporating interventions into the Plan of Care with consideration of the participant's assessed preferences.
  • Include necessary back-up arrangements such as availability and use of family members or other informal supports to assist the participant.
  • Include the applicant/participant, his/her family, significant others, legally designated representative(s) and/or other representatives of his/her choosing in significant others in Plan of Care development.
  • Maintains good working relationships with the family and other caregivers. Notifies LDSS of any changes in family or caregiver support.
  • If disagreements occur in Plan of Care development, confer with the LDSS for remediation; if agreement can not be reached, comply with decisions of the local professional director who determines appropriate adjustments.
  • Assist LDSS staff in determining necessary services and costs. May propose budget for individual for LDSS approval.
  • Discuss and resolve with the LDSS any findings regarding unmet needs.
  • Assist LDSS in referring ineligible individuals to alternate services.
  • Provide all applicants approved for waiver participation with a copy of the bill of patient's rights, documenting in the clinical record that this has been given to the participant.
Plan of Care Update/Revision
  • Repeat the Plan of Care process at least every 180 days or more frequently when circumstances warrant.
  • In accordance with Medicare Conditions of Participation, review the Plan of Care at least every 60 days or more frequently when there is a significant change in the individual's condition and promptly alert the physician of any need to alter services requiring the physician's order.
  • Use the range of available options to continue to meet the individual's service needs, e.g. use of paper credits, budget annualization, use of appropriate alternative waiver/non-waiver services, maximization of third party resources, increased use of informal supports, including other community resources. Also, coordinate (with the LDSS representative) any changes in services with the family/caregivers to help them understand the changes.
  • Notify LDSS concerning hospital admissions and other changes in status that might indicate the need for discharge from the LTHHCP.
  • Seek appropriate alternatives when decreasing services or referring to alternative community based services or for institutionalization; provide comprehensive information to any agency to which individual referred
Service Delivery
  • Implement and oversee the Plan of Care, coordinating and monitoring the provision of LTHHCP services. With the LDSS representative) arranges for the non-LTHHCP services.
  • Conduct aide supervision as required by applicable regulations.
  • Address with the LDSS any issues identified during LDSS home visits.
Participant Choice
  • When "alternate entry" is initiated for an individual: (a) offer all potential waiver participants informed choice between community-based services and institutional care; and (b) for those choosing community-based care, discuss and offer choice of MA waiver programs and non-waiver services/programs such as the Personal Care Services Program or Managed Long Term Care
  • Offer choice of waiver services providers from among qualified/participating providers. The applicant/participant has the right to choose from among the available providers.
III. The waiver must have an adequate system for assuring all waiver services are provided by qualified providers.
  • All providers must initially and continually meet required licensure and/or certification standards and adhere to other state standards prior to furnishing waiver services.
  • All non-licensed providers/non- certified providers must be monitored to assure adherence to waiver requirements.
  • Provider training must be conducted in accordance with state requirements and the approved waiver.
 The LDSS must:
  • Use only those agencies certified by DOH and approved for enrollment in eMedNY as the applicant's/participant's LTHHCP agency.
  • Participate in provider training and technical assistance opportunities at the request of DOH.
  • Contact DOH and/or call the Home Health Hotline if there is a concern related to the quality of services provided by the LTHHCP agency and the agency is not remediating the problem.
 The LTHHCP agency must:
  • Remain in compliance with all federal and State certification and survey requirements, including:
    • orientation and ongoing training of staff and an annual performance evaluation which includes an in home visit to observe interaction with participants;
    • maintenance of appropriate contracting policies and procedures to fulfill the LTHHCP agency's responsibility for assuring all contracted staff are appropriately licensed, certified and in compliance with established qualifications for providing LTHHCP services;
    • maintenance of an agency quality management process which includes an annual overall evaluation of its total program by professional personnel.
  • Comply with applicable State fingerprinting requirements for prospective employees.
  • Enroll in eMedNY, submitting and annually updating all required certification statements.
  • Participate in provider training and technical assistance opportunities at the request of the LDSS or DOH.
IV. The waiver must have an adequate system for identifying, addressing and preventing instances of abuse, neglect and exploitation.
  • Abuse, neglect and exploitation must be identified, addressed and prevented on an ongoing basis.
 The LDSS must:
  • Monitor the health and welfare of individual participants.
  • Assure staffs involved with assessment, reassessment and service delivery or oversight under the waiver comply with all NYS requirements for reporting abuse and/or neglect applicable to their professional status.
  • Refer cases as appropriate to the LDSS' Protective Services for Adults or Child Protective Services programs; document such referrals in the case record; and, work with those programs as appropriate on resolution of issues.
  • Monitor follow-up activity to assure corrective action.
  • Comply with DOH reporting specifications regarding identification of significant occurrences of abuse, neglect and/or exploitation and corrective actions.
  • As provided in for in the Consumer Information Booklet, provide participants with the DOH Home Health Hotline phone number.
 The LTHHCP agency must:
  • Monitor the health and welfare of individual participants.
  • Assure staffs involved with assessment, reassessment and service delivery or oversight under the waiver comply with all NYS requirements for reporting abuse and/or neglect applicable to their professional status.
  • Comply with federal and State requirements for policies and procedures which support the prevention, identification and/or remediation of abuse, neglect and exploitation, e.g. requirements for agency quality management processes to report adverse incidents/outcomes for investigation, action and quality improvement.
  • Refer cases as appropriate to the LDSS' Protective Services for Adults or Child Protective Services programs; document such referrals in the case record; and, work with those programs as appropriate on resolution of issues.
  • Provide participants with the DOH Home Health Hotline phone number
V. The State must retain ultimate administrative authority over the waiver and administration must be consistent with the approved waiver application.
  • The State Medicaid agency must retain ultimate administrative authority by exercising oversight of the performance of waiver functions by other State and local/regional non-State agencies and contracted entities.
 The LDSS must:
  • Participate as requested by DOH in State waiver management staff review of case records, including completion of any self- assessments required prior to State on-site review and implementation of any identified corrective actions.
  • Participate as requested by DOH in quarterly technical assistance advisory calls and/or other training activities.
  • Maintain accurate and complete case documentation and comply with all DOH specified tracking/reporting requirements.
 The LTHHCP agency must:
  • Participate as requested by the LDSS and DOH in State waiver management staff review of case records, including completion of any self-assessments required prior to State on-site review and implementation of any identified corrective actions.
  • Comply with all State survey requirements, including implementation of any corrective actions that must be implemented pertaining to the assurances, e.g. LOC assessments/determinations. For LTHHCPs which are Certified Home Health Agencies, these surveys serve as a primary mechanism for the State to assure that the agencies are complying with all Medicare Conditions of Participation pertaining to the assurances, e.g. components of plan of care development.
  • Participate as requested by the LDSS and/or DOH in technical assistance advisory calls and/or other training activities.
  • Maintain accurate and complete case documentation and comply with all tracking/reporting requirements specified by the LDSS and/or DOH.
VI. The waiver must maintain an adequate system for assuring financial accountability.
  • Claims must be coded and paid for in accordance with reimbursement methodologies specified in approved waiver application.
 The LDSS must:
  • Compute each individual's monthly MA expenditures based upon the Summary of Services Requirements and assure expenditures will be within the approved monthly budget cap before authorizing the individual's participation in the waiver.
  • Give final approval on budgets proposed by LTHHCP provider. Maintain and authorize use of "paper credits" for participants.
  • Review the participant's Plan of Care and monitor expenditures at least every 180 days as part of the reassessment process.
  • Incorporate any changes in the Summary of Service Requirements into monthly budget and adjust paper credits. Authorize any changes that exceed the approved budget by more than 10%.
  • Identify an approved participant's authorization for the waiver by entering Code 30 in the Welfare Management System's Restriction/Exception Code.
  • When authorizing State Plan services for an applicant/participant such as PERS, assure that those services are not duplicated within the waiver Plan of Care.
  • Maintain necessary documentation and provide information requested by DOH and/or federal and State audit agencies necessary for program oversight.
 The LTHHCP agency must:
  • Notify LDSS on the first working day following the noting of a change in an individual's condition and concerning any changes in the authorized Summary of Service Requirements.
  • Seek prior authorization for any service change that exceeds the spending cap for the individual by 10% or more when the level of service changes from SNF to HRF.
  • Comply with eMedNY enrollment and billing requirements.
  • Bill Medicare and third-party insurance for services, when appropriate, prior to billing Medicaid. Inform LDSS of any third-party insurance coverage.
  • Submit claims only for individuals who have been authorized by the LDSS as LTHHCP participants.
  • Secure an independent audit of their financial statements attesting to the accuracy of their annual cost report submitted to DOH.
  • Maintain necessary documentation and provide information requested by DOH and/or federal and State audit agencies necessary for program oversight.