NHTD and TBI Waiver Transition Workgroup Meeting

  • Meeting Minutes is also available in Portable Document Format (PDF, 61KB)

Meeting #2 - November 30, 2015, 1:00 pm - 3:00 pm
Empire State Plaza, Meeting Room 6
Albany, NY 12242

Welcome and introduction - Rebecca Corso, Deputy Director, Division of Long Term Care

  • Introduction of Workgroup members
  • Review of meeting agenda:
    1. Summary presentation of Workgroup discussions to date;
    2. Presentation on Peer Mentoring, Lindsay Miller, Executive Director, New York Association on Independent Living (NYAIL); and
    3. Comments from Workgroup members and audience.

Presentation of Workgroup discussions to date - Rebecca Corso

  • The transition of the NHTD and TBI waiver programs into managed care is in keeping with the Medicaid Redesign Team (MRT) goal of Care Management for All.
  • In order to receive long term care services, and continue receiving current waiver benefits, current NHTD and TBI participants will be offered a managed care program:
    1. Managed Long Term Care (MLTC) - MLTC mainly serves the dual participants in need of 120 days or more of community-based long term care services, or
    2. Medicaid Managed Care (MMC) - MMC serves the non-dual participants and currently has approximately 6 million members enrolled.
  • Review of the Transition Timeline:
    1. The Department intends to have a draft transition plan prepared for the Workgroup to review by the next meeting scheduled for January 27, 2016.
    2. The public comment period is scheduled for April 1 - May 1, 2016.
    3. After the public comment period, the Department will synthesize the comments and determine the changes to be made based on those comments. A revised transition plan will incorporate the comments or explain why comments were not included and is scheduled to be submitted to the Centers for Medicare and Medicaid Services (CMS) by June 30, 2016.
    4. The Department is aiming for approval of the transition plan by November 30, 2016.
    5. Following approval of the transition plan, a series of announcement letters will be sent to waiver participants. The notices will explain the transition and let individuals know they need to pick a managed care plan.
    6. Implementation of mandatory enrollment is scheduled for March 1, 2017.
    7. Managed care services are scheduled to begin on April 1, 2017, when the waiver programs will end.
  • All previous subcommittee meeting minutes are available on the MRT #90 website.
  • Review of Proposed Actions:
    1. Current NHTD waiver services not currently included in the MMC and MLTC benefit package: Home Visits by Medical Personnel and Peer Mentoring will not be transitioned to the plans and will not be included in the benefits packages. Both services were not utilized under the waiver program, so they will not be added to the managed care benefit packages. Other Peer Mentoring resources will be discussed by NYAIL Executive Director Lindsay Miller to address concerns regarding the discontinuation of this service.
    2. New individuals (those not currently active as waiver participants) must continue to meet waiver eligibility to gain access to the transitioned services under managed care.
    3. The Regional Resource Development Centers (RRDCs) will continue to have a role in the coordination of services including Service Coordination and other non-State Plan services (Community Integration Counseling (CIC), Positive Behavioral Intervention and Support Services (PBIS), Independent Living Skills Training (ILST)). The RRDC role will be critical in ensuring continuity of services throughout the transition.
    4. Service Coordination will be included as a managed care benefit in addition to care coordination, based on need. In order to receive Service Coordination, participants must have a Nursing Home Level of Care, plus a diagnosed moderate cognitive impairment.
  • Workgroup comments and questions on proposed actions:
    1. A Workgroup member expressed concern regarding service coordination and accountability under managed long term care. There was concern that participants would have difficulty accessing the service and identifying appropriate providers. The Department responded that it will continue to monitor the process for Service Coordination selection and the provision of services.
    2. There was discussion regarding the definition of moderate cognitive deficit as a criteria for service coordination. The Department responded that the exact definition of moderate cognitive impairment is still under review and consideration. This could include but is not limited to ICD-10 and DSM V diagnosis.
    3. There was discussion regarding State plan vs. non-State plan services. Current waiver services that are included in the State Plan Amendment (SPA) for Community First Choice Option (CFCO) are considered State plan services. Current waiver services that are not included in CFCO are considered non-State plan services and include Service Coordination, CIC, ILST, and PBIS. Both current waiver participants and new individuals who meet eligibility requirements will have access to these services.
    4. The CFCO SPA assumes that service coordination is available, although it is not a CFCO service. More discussion is needed on how the CFCO SPA affects the transition. The NYSDOH is still determining how CFCO will be implemented.
    5. A Workgroup member raised concern about using the RRDC in addition to a managed care plan. The Department stated that it is responding to the concern that Managed Care Organizations (MCOs) do not have expertise regarding the waiver target populations and indicated that the RRDC will provide assistance in ensuring continuity-of-care. If an individual prefers not to work with the RRDC to receive service coordination and other services, they can work with the care manager at the managed care plan.
    6. A Workgroup member asked if Structured Day Program services are included in CFCO and if this service will be covered as a State plan service. The Department will look at the crosswalk of services and respond.
    7. Concerns were presented regarding the role of the RRDC as it continues in the managed care environment. Steps will need to be taken to ensure that there is not a duplication of work and paperwork. These details should be discussed at future subcommittee meetings to include feedback from both the plans and the RRDCs.
    8. Additional comments were provided regarding moderate cognitive impairment as a criteria for service coordination. One workgroup member suggested that the criteria should be removed in order to allow access to the service for all managed care recipients who may benefit from the service.
    9. A Workgroup member asked if the role of the RRDC would be ongoing or only continue through the transition. The Department responded that the intention is for the RRDC to continue past the transition process. The State would contract with the RRDCs and have oversight over RRDC operations. There will need to be coordination of efforts between the RRDC and the managed care plans. The RRDC, service coordinator, and participants will have the ability to recommend a plan of care then submit it to the managed care plan for approval. The MCO can accept, deny, or modify the recommended service proposal. If there is an unsatisfactory outcome, the participant has the right to appeal through the Fair Hearing process.
  • Continued Review of Proposed Actions:
    1. Establish a two-year continuity-of-care period for participants and service providers.
    2. Managed care organizations will be required to contract with providers who serve 5 or more current waiver participants; who will continue to provide services to participants unless a health/safety concern exists; and who assure that appropriately licensed personnel are employed to provide and/or supervise services.
    3. Participants will have the choice to maintain his/her existing services and providers for 90 days. If the same need remains after 90 days, participants will have the option to keep the same providers for up to two years if the providers meet the required conditions.
  • Continued Workgroup discussion and comments on proposed actions:
    1. A Workgroup member asked if the proposed licensed personnel qualifications are consistent with the current qualifications. The Department responded that the intent is to maintain continuity-of-care. Qualifications for providers will remain as currently established in the waiver application, however there is a likelihood that qualifications for supervisors will increase.
    2. A Workgroup member asked what will happen after the two-year continuity-of-care end for providers ceases. The Department responded that the managed care plans may choose to continue to contract with that service provider. If the managed care plan no longer chooses to work with the providers after this two year period, the participant has the option to stay with the plan and choose a new provider or change plans.
    3. A Workgroup member expressed concern that after the 90-day continuity-of-care for services, service decisions made by the managed care plan will be based on cost. The Department responded that decisions about care will be based on the need of the plan member, not cost.
    4. A member of the audience asked how the Department will ensure that managed care plans provide the same level of service as is currently available. The Department responded that there will be trainings to ensure accountability and knowledge about the current service recipients and their services. If there are grievances, the Department has set up an independent ombudsman for participants to contact with concerns/complaints. A representative from a managed care plan responded that plans participated in extensive training when the transition to managed care began in 2012 in order to better understand patient-centered care plans. The plans have undergone a transition as well and believe that the grievance/Fair Hearing process does work. The plans have a goal to build a plan of care that works for both the plan and the member.
    5. An audience member asked if the services will continue to be governed by the TBI manual when they transition to managed care. NYSDOH responded that the provisions of the Program Manuals will be considered when moving forward with the transition plan and talks with the managed care organizations.
    6. A Workgroup member sought to re-confirm that in addition to the two-year continuity-of-care for providers, the current rate structure for waiver providers will continue through the transition process. NYSDOH confirmed this position.
    7. A Workgroup member requested a draft of the guidelines outlining how the RRDCs will function within the managed care environment. The Department responded that it does not have an official document to share at this time and how these functions will be determined has not yet been finalized.
    8. A Workgroup member expressed concern that the TBI/NHTD populations may not have the ability to fully understand the grievance process, and as a result, services may be jeopardized.
    9. A managed care representative commented on the willingness of plans to work with this population and the providers in order to create a collaborative process throughout the transition. Plans invite providers to have a conversation about the process now, outside of the Department's meetings, and begin to develop a partnership.
    10. A Workgroup member suggested holding regional meetings by county.
    11. A Workgroup member suggested the Department consider lowering the requirement for providers to serve five or more current waiver participants in order to be granted continuity-of-care for two years.
  • Outreach and Education Update
    1. The Department recognizes the extensive needs of the waiver population and will ensure that Maximus is prepared to appropriately and effectively handle their concerns.
  • UAS-NY Update
    1. The Department will continue to use the UAS-NY to determine care needs for participants/plan members in managed care.
    2. A Workgroup member noted that a UAS score of 5 equates to nursing home level of care and asked what is the indicator that an individual needs for 120 days or more of community-based long term care services? The Department responded that this is not determined by the UAS score, but is an assessment of the services that the individual needs.
    3. Several Workgroup members and audience members expressed concerns over the use of the UAS and its ability to accurately capture the needs of individuals with a cognitive deficit. The need for education and training for anyone working with individuals with a cognitive deficit was expressed.
    4. There are additional concerns that the compensation and scheduling of assessments creates an incentive for assessors to rush through the assessment process. The Department will take these concerns under advisement.
    5. An audience member noted that the UAS as an assessment tool is only as good as the assessors that are using it and expressed the need for other individuals involved in a participant/member's care to be present at the time of the assessment. The Department agrees that it is important and recommended to have others present during the time of the assessment.
    6. A Workgroup member asked how many individuals on the waiver score below a 5 on the UAS. The Department responded that it does not have reliable data at this point to present to the Workgroup. There are a number of factors that currently influence the assessment findings: not all TBI waiver participants have had a UAS completed, additional training for assessors, and willingness of the participant to engage in the assessment.
    7. A Workgroup member asked if a physician could override a UAS score. The Department responded that this is currently not an option.
  • Housing Subsidy discussion
    1. The Department reiterated its commitment to maintain the housing subsidy for individuals who are receiving a subsidy at the time of the transition.
    2. A Workgroup member requested that someone involved in the decision to not include future TBI survivors in a housing subsidy program be present at the next meeting to discuss this decision with the group. The Department responded that it agrees housing is a valid concern but that it is outside the scope of the mission of this workgroup. Housing is not a waiver service and as such will not be included in the transition plan which is to be submitted to CMS.
    3. It was presented that there are ongoing discussions with CMS to provide Medicaid funding for housing. The Department is committed to supporting housing initiatives through its MRT initiatives; however, this is not the focus of this Workgroup.

Presentation on Peer Mentoring - Lindsay Miller, Executive Director, New York Association on Independent Living

  • Discussion and questions from the Workgroup:
    1. A Workgroup member asked if the NYAIL peer program is only for individuals who participate in the Money Follows the Person/Open Doors (MFP) program. Ms. Miller responded that the peer program focuses on those individuals transitioning from nursing homes to community living. The current structure of the contract does allow that exceptional cases may be assisted and will not be refused by the program.
    2. A Workgroup member asked if there was a cap on services provided under the program. Ms. Miller stated that there is currently no limit on services; however, the budget must be considered as the program expands.
    3. A Workgroup member asked if the Independent Living Centers (ILCs) that contract with the Peer Mentoring program are the same as those that contract with the RRDCs. Ms. Miller responded that they are the same.
    4. The Department funds the program.

Meeting Wrap up:

  • Questions and comments from phone participants:
    1. How are managed care eligibility evaluations conducted and maintained? The Department responded that there is an assessment every 6 months or if there is a significant change or event that prompts an assessment prior to the 6 month mark. The assessment is conducted by nurses employed or contracted through managed care plans.
    2. Will there be a limit on caseloads for service coordination? The Department does not plan to dictate to plans a specific caseload requirement. NYSDOH recognizes that the plans currently coordinate weighted caseloads based on risk and hierarchy of need. This practice will continue.
    3. How will Conflict Free Evaluation and Enrollment Centers (CFEEC) be involved? The Department responded that individuals who are in the waiver programs will not have to go to a CFEEC at the time of the transition; it is assumed they are eligible for MLTC or MMC. New individuals seeking services will be assessed through the CFEECs.
  • Final comments from the workgroup and audience:
    1. An audience member reinforced the need for individuals with a cognitive deficit to have an advocate to assist with language issues and the grievance process.
    2. The Department will schedule additional subcommittee meetings prior to the next Workgroup meeting in January.

Meeting was adjourned at 3:00 pm.