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

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

There were 993 members that transferred from Kalos to VNS. A listing of the personal care hours each member received 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 993 Kalos enrollees who transferred to VNS one year following expiration of the continuity of care period is presented below. On average, members saw a reduction of 0.23 hours.

Service Authorization changes for Kalos Enrollees who transferred to VNS
Decrease 164
Disenrolled 83
Longterm Care 4
Medical Adult Day Care (MADC) 1
Member Requested 1
Mutual Case With Spouse 1
No Current Services 1
No Comment 73
Increase 251
No Current Services 2
Mutual Case With Spouse 1
No Comment 248
No Change 578
Disenrolled 40
Longterm Care 2
Medical Adult Day Care (MADC) 5
Member Was Reduced But Won Appeal 3
Skilled Nursing Services 2
No Comment 526
Grand Total 993

Additionally, from the sample of 993, 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 Person Centered Service Plan (PCSP) from Kalos prior to the transition, PCSP 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.