GIS 13 MA/014: Level I Personal Care Services and Consumer Directed Personal Assistance Services in Managed Long Term Care

The purpose of this General Information System (GIS) message is to advise local departments of social services (LDSS) about changes to policies and protocols pertaining to provision of Level I Personal Care Services and Level I type Consumer Directed Personal Assistance Services (together referred to as Level I service) within the construct of the managed long term care program (MLTC). Specifically, this guidance pertains to circumstances in which Level I service is the sole community based long term care service provided to a consumer. This GIS expands on and clarifies MLTC Policies 13.15 and 13.16 (attached).

For purposes of determining eligibility to enroll, or remain in MLTC, individuals who only require assistance with housekeeping tasks do not meet the intent of community based long term care services and are thus not eligible to enroll or remain in MLTC. Individuals with a need for assistance with both Instrumental Activities of Daily Living (e.g. housekeeping tasks) and Activities of Daily Living (e.g. bathing, grooming, toileting, etc.) and meet the eligibility standard of requiring more than 120 days of community based long term care services will continue to be appropriate for MLTC.

Any individuals not presently in receipt of Personal Care Services or Consumer Directed Personal Assistance Services who are initially assessed by the MLTC plan as needing only Level I services, do not meet the threshold for enrolling into MLTC. Therefore, local districts should resume accepting and processing new applications involving solely Level I services. Individuals should be referred to the LDSS for assessment and if determined to be in need of Level I services, the local district should establish the case on a fee for service basis and provide appropriate notice to the Medicaid recipient. The limitation on authorizing no more than 8 hours per week of Level I services remains in place.

Medicaid eligible individuals already enrolled in MLTC whose assessment determines Level I to be the sole community based long term care service required, must be disenrolled and referred by the plan to the local district. Appropriate notice of disenrollment must be provided by the plan to the individual within five (5) business days from the date it was determined the individual is not eligible for MLTC. Such notice, together with the results of its assessment, must be provided by the plan to the local district or entity designated by the Department. The effective date of disenrollment shall be the first day of the month following the month in which the disenrollment is processed through eMedNY. If the enrollee does not request a (voluntary) disenrollment, such disenrollment will be considered to be involuntary.

Individuals transitioning from MLTC to fee for service Level I services must continue to receive services under the individual's pre-existing service plan for at least 90 days after transitioning to fee for service or until a care assessment has been completed by the LDSS, whichever is later. In addition, the patient/worker(s) relationship should attempt to be preserved for the same 90 day period.

Transitioned individuals retain all fair hearing rights as a result of any proposed reduction, suspension, denial or termination of previously authorized services regardless of whether the MLTC authorization expires following the continuity of care period. These provisions are effective immediately.