Conflict-Free Evaluation and Enrollment Center

Mark Kissinger, Director, Division of Long Term Care
Margaret Willard, Director, Bureau of Managed Long Term Care
Conflict-Free Evaluation and Enrollment Center Webinar

September 22, 2014

Conflict Free Evaluation and Enrollment Center Overview

  • In accordance with NY State´s Special Terms and Conditions (STC) #28, the State is required to develop an independent and conflict-free long term care services and supports (LTSS) evaluation process.
  • Effective October 2014, the State will implement a Conflict-Free Evaluation and Enrollment Center (CFEEC) for individuals seeking Community-Based Long Term Care (CBLTC) services for more than 120 days.

Evaluation and Enrollment Center

  • Maximus will serve as the CFEEC providing evaluation and education services.
  • The State will expand Maximus' current role as enrollment broker New York Medicaid Choice (NYMC) to perform CFEEC activities which will include:
    • Scheduling initial eligibility evaluations for people new to service seeking CBLTC
    • The CFEEC will have 5-7 business days to schedule the evaluation from when the call is received
    • Staffing nurse evaluators to perform in-home evaluations (including hospitals, nursing homes) using the UAS-NY

CFEEC Enrollment

  • CFEEC Policy Highlights:
    • CFEEC will be the only entity authorized to complete initial evaluations.
    • Managed Long Term Care Plans (MLTCPs) will no longer be permitted to enroll new individuals until the CFEEC has conducted an initial evaluation to determine CBLTC eligibility.
    • MLTCPs will continue to be responsible for completing their own assessments which determine the plan of care.
    • This policy does not apply to individuals transferring from one plan to another

CFEEC Eligibility

  • The CFEEC will evaluate consumer´s eligibility for one of the four MLTC products:
    • Partially Capitated Plans
    • Program of All-Inclusive Care for the Elderly (PACE)
    • Medicaid Advantage Plus (MAP)
    • Fully Integrated Duals Advantage (FIDA) (To be implemented January 2015)

CFEEC Evaluation Process

  • UAS-NY:
    • CFEEC must complete the Uniform Assessment System (UAS) for all evaluations prior to all MLTC plan enrollments.
    • Staff at CFEEC, including the nurse evaluators, are trained in the UAS and have the appropriate levels of access granted.
    • Once the evaluation is completed, if the consumer is eligible for MLTC, they will have the option of selecting a plan and allowing CFEEC to assist with connecting the individual to the plan.
    • The UAS will have a same day completion.

CFEEC Evaluation Process For Nursing Home Residents

  • Nursing Home Residents Returning to the Community Have Two Options:
    • If the NH resident is not enrolled in a MLTCP, the resident will be required to contact the CFEEC for an evaluation of CBLTC eligibility.
    • If the NH resident is enrolled in a MLTCP, the resident is not required to contact the CFEEC to meet CBLTC eligibility.

CFEEC Notices

CFEEC has an inventory of Long Term Care (LTC) notices which include:

  • LTC Approval - Qualified for LTC
  • LTC Denial - Unqualified for LTC (includes Fair Hearing Rights)
  • Notice of Review - Dispute Resolution process will occur
  • LTC Approval Overturned - Review determined ineligible for LTC needs (includes Fair Hearing Rights)
  • LTC Approval Upheld - Review determined appropriate for LTC needs
  • LTC Approval Expired - Consumer qualified for LTC but no plan selected

CFEEC Dispute Resolution Process

  • If there is a discrepancy between the CFEEC eligibility determination and the MLTCP assessment, a dispute resolution process will begin.
  • Dispute Resolution Protocol:
    • MLTCPs will submit a Disagreement Request to CFEEC
    • Clinical staff will review determinations
    • Depending upon the review outcome, cases may be escalated to the NYS Medical Director for a final determination within 3 business days

CFEEC Roll-out Schedule

CFEEC Implementation is scheduled to begin in October 2014 and will be phased-in by Region.

  • Region 1 - October 2014: New York (Manhattan) & Bronx
  • Region 2 - November 2014: Kings (Brooklyn), Queens, Nassau, & Richmond (Staten Island)
  • Region 3 - February 2015: Westchester & Suffolk
  • Region 4 - March 2015:
    • East Hudson (Columbia, Dutchess, Putnam)
    • Catskill (Rockland, Orange, Ulster, Greene, Sullivan)
    • Capital (Warren, Washington, Saratoga, Fulton, Montgomery, Schoharie, Schenectady, Albany, Rensselaer)
    • Other (Erie, Monroe, Onondaga)
  • Region 5 - April 2015:
    • Southern Tier (Tompkins, Cortland, Tioga, Broome, Chenango, Otsego, Delaware)
    • Finger Lakes (Wayne, Ontario, Livingston, Seneca, Cayuga, Yates, Schuyler, Chemung, Steuben)
    • Western (Chautauqua, Cattaraugus, Allegany, Wyoming, Genesee, Orleans, Niagara)
  • Region 6 - May 2015:
    • Central (Jefferson, Oswego, Lewis, Oneida, Herkimer, Madison)
    • Northern (St. Lawrence, Franklin, Clinton, Essex, Hamilton)

Next Steps

QUESTIONS?

CONTACT US

Questions and/or Comments:

CFEEC e-mail: CF.Evaluation.Center@health.ny.gov

MRT 90 website: http://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm

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