APPENDIX P

  • Attachment A is also available in Portable Document Format

SAA ENROLLMENT PROCESS

(New York State Department of Health - Revised August 2022)

New York Medicaid Choice (NYMC), the Enrollment Broker contracted by the State Administrating Agency (SAA), carries out New York State's role in the enrollment process to include confirmation of eligibility or ineligibility in cases where the consumer fails to meet the criteria as set forth by the State and Federal requirements (CFR 460.150(b)). This Appendix P sets forth the process by which Program of All-Inclusive Care for the Elderly (PACE) Organizations and New York State's Conflict Free Evaluation and Enrollment Center (the CFEEC), or its successor, work together to establish and validate eligibility criteria for enrollment of Applicants to PACE.

  1. PACE Direct Eligibility Option Assessment Process. Pursuant to the terms of its 1115 Waiver Demonstration, New York State (NYS) has established the CFEEC for Medicaid-eligible new Applicants seeking enrollment in PACE or any of NYS's Managed Long Term Care (MLTC) products. Currently, an Applicant seeking to enroll in a MLTC product other than PACE must contact the CFEEC, rather than contacting MLTC plans directly for assessment. In accordance with this Appendix P, Applicants seeking only to enroll in PACE may contact the CFEEC for assessment or, at the sole option of the Applicant, contact a PACE Organization directly to conduct an assessment in order to confirm on behalf of the SAA a Nursing Facility Level of Care (NF LOC) and the need for a continuous period of more than 120 days of Community Based Long Term Care Services (CBLTCS). Where the SAA delegates to the PACE Organization to perform this assessment, it establishes “a PACE Direct Eligibility Assessment” enrollment for both Medicaid and Medicaid Pending individuals, subject to the following:
    1. In cases where, under this Direct Eligibility option, the PACE Organization has chosen to conduct its own eligibility determination, these Applicants are subject to a subsequent CFEEC validation review as further described in Section 6 herein. For any cases where the CFEEC determines that the Applicant does not meet the NF LOC criteria, the CFEEC will forward the results of the assessment to NYMC and the PACE Organization. NYMC will review the CFEEC assessment and any materials submitted by the PACE Organization and, if appropriate, issue a prospective involuntary disenrollment notice, in accordance with CFR 460.164, to the Applicant if the Applicant is determined to be ineligible for continued PACE enrollment. NYMC will also notify the PACE Organization of such notice and determination.
    2. For Direct Eligibility option cases, the PACE Organization must provide (or coordinate with NYMC to provide) the Applicant with written notice designed by the SAA informing the Applicant about the Direct Eligibility option, the subsequent reviews of such cases by the CFEEC, and the rights and the responsibilities of the Applicant if Applicant is not determined eligible by the PACE Organization or the CFEEC, either before or after Direct Eligibility is determined.
    3. Where a disenrollment notice is issued, the PACE Organization shall work to ensure a safe discharge, including the appropriate handoff to other services and supports, and the PACE Organization shall disclose the effectuated disenrollment to the Office of the Medicaid Inspector General (OMIG) to determine whether there shall be a return of any and all payments made to the PACE Organization for the Applicant as a result of the inappropriate Direct Eligibility Enrollment, consistent with rules and processes established by NYS, and consistent with the SAA's PACE Model Contract.
  2. Need for Direct Eligibility. NYS has established this delegated PACE Direct Eligibility option to allow PACE Organizations to provide an expedited alternative for enrolling Applicants who might otherwise be directed to a nursing home placement. Otherwise, potential PACE Applicants may elect nursing home placement due to the comparatively fast timeframe for establishing nursing home placement, as compared to PACE. Nursing homes will accept admissions with Medicaid and/or Medicare eligibility pending with an assurance of private payment should such eligibility not be established. Accordingly, this process for PACE supports the SAA's goal of increasing enrollment in PACE, as a specialized integrated care plan for dual eligibles, which is federally recognized and has demonstrated its ability to offer viable alternatives to institutional care.
  3. Eligibility Criteria. When elected by an Applicant, the PACE Organization will perform the initial Applicant review utilizing the Uniform Assessment System-NY (UAS-NY) Community Health Assessment (CHA). The PACE Organization shall use the UAS-NY CHA to perform initial Applicant assessments and to establish NF LOC eligibility. The PACE Organization may determine an Applicant as meeting eligibility criteria if the Applicant has a NF LOC (score of 5 or above) and needs a continuous period of more than 120 days of Community Based Long Term Care (CBLTC) services. For cases in which the Applicant contacts the CFEEC, the CFEEC will conduct the initial Applicant review against these eligibility criteria. The PACE Organization is responsible for conducting all required reassessments to verify ongoing eligibility criteria, notwithstanding the Applicant's process for establishing PACE eligibility and enrollment.
  4. Definition of CBLTC Services. Consistent with Art. III Section A.1 and Appendix F of the SAA's PACE Model Contract, CBLTC services are defined as Nursing Services in the home; Home Health Care (which is further defined as traditional Certified Home Health Agency services such as therapies or home health aide service in the home); Personal Care Services in the home; Adult Day Health Care; Private Duty Nursing; and Consumer Directed Personal Assistance Services. Attendance at the PACE Center, due to the medical components provided, is the equivalent to the need for Adult Day Health Care as per the definition of CBLTC services.
  5. Notification to the CFEEC. For Direct Eligibility cases where the enrollment was accepted, the PACE Organization must notify NYMC of the result of each initial assessment, including:
    1. In the case of a determination of ineligibility for enrollment due to not meeting NF LOC, the reasons for such a determination such that the NYMC can issue a notice of ineligibility informing the Applicant of ineligibility for enrollment and/or perform an assessment for eligibility for other MLTC products;
    2. In the case where the initial assessment by the PACE Organization showed that the Applicant did not meet NF LOC eligibility criteria, the Applicant retains the right to seek PACE enrollment by going through the established CFEEC process;
    3. In the case of an acceptance for enrollment due to meeting the NF LOC eligibility criteria, the date of enrollment shall be on the first day of the next available month for enrollment; and
    4. The Applicant's Medicaid Client Identification Number and/or the Applicant's Medicaid Pending status.
  6. CFEEC Verification Review. For Direct Eligibility cases, the CFEEC will verify the validity of PACE enrollment for each enrolled Applicant within 30 days after enrollment of the Applicant. Depending on the case, the CFEEC may either elect to conduct this verification review process through scheduling an assessment of the individual utilizing the eligibility criteria, or conduct a “desk review” of the Contractor's assessment and records collected from the PACE during its Direct Eligibility review.
    1. If this verification review determines that the PACE Organization enrolled an individual who did not meet the NF LOC eligibility criteria, the CFEEC will forward the results of the assessment to NYMC and the PACE Organization. In cases where the CFEEC denies the eligibility both the PACE Organization and the Applicant retain the right to appeal the negative determination.
    2. Upon notice of the verification review results indicating a prospective disenrollment will be forthcoming from NYMC, the PACE Organization shall be responsible for ensuring that the Enrollee is transitioned to the appropriate level of coverage and shall work to ensure appropriate handoff to other services and supports. Additionally, the PACE Organization shall disclose the effectuated disenrollment to the OMIG to determine whether there shall be a return of any and all payments made to the PACE Organization for the Applicant as a result of the inappropriate Direct Enrollment, consistent with rules and processes established by NYS, and consistent with the SAA's PACE Model Contract.
    3. Where the verification review process results in a disenrollment notice from NYMC, the Enrollee may request a fair hearing of the determination consistent with state and federal requirements. During the pendency of a fair hearing request, the Enrollee may continue to receive PACE services in accordance with state and federal requirements where aid continuing has been granted.
    4. Where verification reviews demonstrate a pattern of inappropriate Direct Eligibility determinations by a PACE Organization, as evidenced by the higher of ten percent (10%) or ten (10) (or more) eligibility enrollments of that PACE Organization not adhering to the eligibility criteria in any particular month, the Direct Eligibility process as described in this Appendix P shall be suspended upon written notification by the SAA to the PACE Organization. If an Applicant is successful at overturning the CFEEC's determination of PACE eligibility upon appeal, this enrollment will not count towards the threshold of inappropriate Direct Eligibility determinations.
    5. Any suspension of the Direct Eligibility process shall last between six (6) months and twenty-four (24) months as determined by the SAA and identified in the written suspension notice to the PACE Organization. Reinstatement of the eligibility process may be further conditioned on the PACE Organization accepting and meeting or surpassing any requirements outlined in the PACE Organization's corrective action plan to address the identified deficiency(ies) related to its eligibility process. In this fashion a suspension of the eligibility process may be indefinite should the PACE Organization fail to address or adhere to the applicable corrective action plan. Nothing in this section or Appendix shall be construed to preclude or preempt the SAA from imposing any other sanction, penalty, or other enforcement action for non-compliance with the requirements herein and the SAA's PACE Model Contract.
  7. Reassessments and Continued Coverage. On an annual basis, the PACE Organization will reassess enrollees to determine adherence to the eligibility criteria. The PACE Organization will conduct reassessments using the UAS-NY CHA. Those enrollees who no longer meet the NF LOC eligibility criteria, but in the absence of continued coverage under the PACE program, would reasonably be expected to meet the eligibility criteria within the next six months, will be deemed eligible for the program. This determination would be based on the presence of at least one of the following criteria not captured by the UAS-NY CHA:
    1. Severe cognitive impairment which necessitates cueing or provision of services for the participant to complete activities of daily living and to comply with the medical regimen for chronic disease;
    2. History of numerous hospitalizations and/or trips to the emergency room, and the ability of the PACE Organization to avert hospitalization and/or emergency room use through medical management;
    3. Complex medical conditions and care management needs requiring continuous clinical oversight by the multidisciplinary team for the participant to remain medically stable; and
    4. Psychiatric diagnoses and behaviors requiring constant intervention by the PACE Organization. In the absence of support and services, the participant would likely be unable to complete activities of daily living and comply with medical regimen for chronic disease.
  8. SAA Review and Oversight. The SAA will review and approve the PACE Organization's enrollment, Direct Eligibility determination and annual reassessment procedures to ensure compliance with each process.
  9. Medicaid Pending Status. A PACE Organization may choose to enroll Applicants whose coverage status is “Medicaid Pending” (i.e., in the process of being determined for Medicaid eligibility). In cases where the Applicant's Medicaid coverage is ultimately denied due to the failure to meet financial criteria for Medicaid eligibility, the PACE Organization may seek private pay remuneration for services rendered so long as the Applicant's financial responsibility for services is documented and agreed to in writing and in advance in the enrollment agreement with the Applicant. The remuneration may not exceed the amount otherwise payable under Medicaid. Further, this provision applies solely to cases in which Medicaid is denied due to financial criteria for Medicaid eligibility. In no case will the Applicant incur any financial liability due to an inappropriate Direct Eligibility NF LOC determination by a PACE Organization.
  10. System Readiness. Implementation of the Direct Eligibility Option and any subsequent amendments will be subject to the timeframes required to effectuate the system changes necessary to accommodate the revised processes.