4403f. (11b.) VNS Health, a Partial Capitation Plan, Post Acquisition Reporting of Member Service Authorizations from Prime Health Choice, a Partial Capitation Plan

VNS Health, a Partial Capitation MLTC plan in New York State, acquired the Prime Health Choice, Partial Capitation membership effective May 1, 2024, and agreed to offer 120 days continuity of care to Prime members.

There were 532 members that transferred from Prime to VNS. A listing of the personal care hours each member was receiving prior to transition, as well as after the transition upon reassessment, along with the changes in personal care hours, if any, was requested. Additionally, for any instance of a decrease in hours an explanation for the decrease with supporting documentation was requested.

The summary of the status of service authorizations for the 532 Prime enrollees who transferred to VNS one year following expiration of the continuity of care period is presented below. Overall, members saw no change in their hours.

Service Authorization changes for Prime Enrollees who transferred to VNS
No Change 532
Member Disenrolled 95
Long Term Care Placement 15
Mutual Case 2
No LTSS on Enrollment 5
Professional Services Authorization at Enrollment 1
No Note / Comment 414
Grand Total 532

Additionally, from the sample of 532, 50 members were selected for a case review. The case review was performed to validate the accuracy of the information provided by the Plan on Service Authorization changes. The information and/or data received consisted of a Plan of Care from Prime prior to the transition, Plan of Care from VNS after reassessment, Care Management notes, and any service request determination or plan action notices sent for the time frame specified. Additionally, after the initial request, the Plan was asked to submit supplementary information for specific enrollees to further clarify potential issues. Upon review of the supplementary information, the accuracy of the submitted data was able to be verified.