MRT 90

Questions generated from responses to the NHTD/TBI Waiver Transition Plan

November 16, 2016

Q: Will NYSDOH exclude the waiver population from managed care?

A: As explained on page 1 of the Waiver Transition Plan, in keeping with the goal of Care Management for All, the State is submitting this transition plan to eliminate the 1915c Home and Community Based Services Waiver for the Nursing Home Transition and Diversion (NHTD) Program and Traumatic Brain Injury (TBI) Program and transition these services into managed care. The timeline for this accomplishment has now moved on several occasions and the current target date for the transition to begin is January 1, 2018.

Q: Why must Service Coordination be Conflict Free?

A: Home and Community Based Services (HCBS) federal regulations effective March 17, 2014 made significant changes to case management services for people enrolled in Medicaid HCBS services. These HCBS regulations, described in 42 CFR441.301(c)(1)(vi), require that states separate case management from service delivery functions. These rules aim to ensure that case management is person-centered and promotes the person’s interest; not that of the agency providing service coordination/case management and HCBS services.

On June 28, 2016 NYSDOH sought guidance from the Centers for Medicare and Medicaid Services (CMS) on how to apply the criteria for Conflict Free Case Management (CFCM) to the NYSDOH waiver service of Service Coordination. The request indicated “Specifically, in what circumstances, may an approved Service Coordination provider offer and provide other waiver services to an individual assigned to their case management caseload? Additionally, in what circumstances can an exemption to the criteria be applied?”

To date, NYSDOH has not received a written response to this inquiry.

In a webinar conducted by CMS in January 2016: Conflict of Interest in Medicaid Authorities, CMS presented the following: “When the same entity helps individuals gain access to services and provides services to that individual, there is potential for Conflict of Interest (COI) in:

A case manager's job is to help the individual and family become well-informed about all choices that may address the needs and outcomes identified in the plan. Conflict of Interest may promote conscious or unconscious “steering.”

States are required to separate case management (person-centered service plan development) from service delivery functions.

Conflict occurs not just if they are a provider but if the entity has an interest in a provider or if they are employed by a provider.”

Q: NYSDOH needs to further clarify when a conflict of interest is present between a Service Coordinator and a service provider as related to service plan development.

A: NYSDOH continues to work with the CMS) to better define these circumstances and to implement sufficient “firewalls” and quality assurance mechanisms to ensure a conflict does not exist.

Q: Will NYSDOH provide additional staff qualifications for the MCOs after the transition period?

A: Notwithstanding any relationship(s) that the MCO may have with providers, the MCO has full responsibility for adhering to and otherwise fully complying with all applicable laws and regulations, standards and procedures required by NYSDOH for the credentialing of providers. The MCO must have a formal process for credentialing providers on a periodic basis (initially and not less than once every three (3) years) and for monitoring provider performance. For providers that are not subject to licensure or certification requirements, the MCO will establish alternative mechanisms to ensure the health and safety of plan members, which could include such activities as criminal background checks or review of abuse registries. The MCO may enter into contracts only with providers who are in compliance with all applicable state and federal licensing, certification, and other requirements; are generally regarded as having a good reputation; and have demonstrated capacity to perform the needed contracted services. All provider contracts must meet the requirements of the NYSDOH Model Contract and applicable state and federal laws and regulations

Q: Several issues have been presented regarding the UAS-NY and the accuracy of the tool to identify cognitive deficits presented by an individual. What course of action will NYSDOH take to remedy the deficiencies in the assessment tool to recognize cognitive deficits?

A: As explained on page 13 of the Waiver Transition Plan, in 2009 NYSDOH entered into a comprehensive review of assessment instruments: the Fox Report was conducted by an external evaluator to report on the development and testing of a uniform assessment tool. At that time, it was determined that the interRAI tool would provide a complementary assessment tool set, as well as “validation and reliability that are missing in current New York Tools.” The interRAI Assessment is a standardized, minimal assessment and screening tool designed for clinical use. The Waiver Transition Workgroup has presented information regarding the UAS-NY on several occasions. NYSDOH implemented additional mandatory training related to cognitive impairment for all assessors. Additionally, NYSDOH advised that a second assessment may be performed if there is a concern that the assessment outcome did not accurately reflect the needs of the individual. There is currently a national workgroup discussing the interRAI Community Health Assessment as directly related to individuals with brain injury. To date, the workgroup has not completed its discussions; however, a final report is anticipated in early 2017. Additionally, NYSDOH has contracted with an outside entity to conduct a validation of a subset of items within the Community Health Assessment. The validation will be conducted across MLTC plans and Regional Resource Development Centers (RRDCs).The validation will consist of a review of medical and care management records compared to submitted Community Health Assessment responses. This review is currently in progress, with a report expected in early 2017. NYSDOH continues to explore ways to enhance the accuracy of the UAS-NY to address the specialized needs of individuals with TBI without compromising the overall integrity and accuracy of the tool as it applies across all Medicaid service recipients.

Q: How will Conflict Free Community Option (CFCO) State Plan Amendment (SPA) be implemented in relationship to the Waiver Transition?

A: As explained on page 3 of the Waiver Transition Plan, in 2011, CFCO became available to all states under the Affordable Care Act of 2010.

Governor Cuomo expressed support for the option in 2011 and directed NYSDOH to appoint an advisory group charged with determining the scope and timing of CFCO. This group subsequently became the Development and Implementation Council required under CFCO statute. On December 18, 2013, the Council reviewed and unanimously approved a proposed State Plan Amendment to implement CFCO in New York State. CMS approved the State’s CFCO SPA on October 23, 2015, with an effective date of July 1, 2015.

CFCO is not a program, a waiver, or a service. Instead, it is an array of consumer-directed services that promote independence, community inclusion, and self-direction. Some of these services are currently available under fee-for-service (FFS), within managed care, and/or within the New York State 1915(c) waivers. The CFCO state plan brings these services together under the umbrella of the Medicaid Program. They must be made available statewide without regard to the consumer’s age, disability, or the services needed to live independently. In a letter dated March 31, 2016, Medicaid Director Jason Helgerson indicated the Office of Health Insurance Programs (OHIP) will:

“Work with all interested parties including the state Legislature and the federal government to ensure a successful transition for TBI/NHTD waiver participants from waiver services to the community first choice option (CFCO) state plan services. The department further agrees to carefully review existing assessment tools to validate their consideration of cognitive deficits with a view to ensuring a continuity of care through January 1, 2018 for individuals who might not qualify for certain services under CFCO.”

Current plans are to fully implement CFCO in July 2017. Information regarding CFCO can be found at: www.health.ny.gov/health_care/medicaid/redesign/community_first_choice_option.htm. Questions may be directed to cfco@health.ny.gov.

Q: What will the future of the Housing Subsidy be?

A: The Medicaid Redesign Team (MRT) Supportive Housing Initiative was developed to expand supportive housing units for high cost Medicaid populations and goes beyond the scope of just the NHTD and TBI housing subsidy programs. Programs provide supportive housing to high-need Medicaid participants through rental subsidies, supportive housing services and capital projects. The MRT Supportive Housing Workgroup was reconvened in 2013 to continue its ongoing work of supportive housing initiatives. The MRT Supportive Housing initiative funds innovative pilot projects, capital, rental subsidies and supportive services. State Agency partners include: Homes and Community Renewal (HCR), Office of Temporary and Disability Assistance (OTDA), Office of Mental Health (OMH), Office for People with Developmental Disabilities (OPWDD), Office of Alcoholism and Substance Abuse Services (OASAS), and the Department of Health's AIDS Institute. These programs continue to expand each budget year. Any NHTD/TBI waiver participant receiving a housing subsidy at the time of transition to managed care will continue to receive his/her subsidy, as designated by annual State budget appropriations. Additionally, housing support is now available to those MLTC members transitioning from nursing homes to their own homes who meet the program criteria. Additional information may be found at: www.health.ny.gov/health_care/medicaid/redesign/supportive_housing_workgroup.htm and www.health.ny.gov/health_care/medicaid/redesign/supportive_housing_initiatives.htm.

Discussions regarding housing are not included in the Waiver Transition Plan, as it is not a waiver service.

Q: Why are oversight and supervision excluded as a discreet service in CFCO?

A: As indicated on page 4 of the Waiver Transition Plan, supervision and/or cueing, currently identified as the waiver service Home and Community Support Services (HCSS), will be incorporated into personal care. This service is utilized when oversight and/or supervision as a discrete service is necessary to maintain the health and welfare of the person living in the community. Oversight and/or supervision may be needed for health and safety monitoring to prevent an individual from harmful activities (for example, wandering or leaving the stove on unattended). Oversight and/or supervision can be accomplished through cueing, prompting, direction and instruction. This service can also be provided to members needing oversight and/or supervision who also require assistance with personal care services. Personal Care Services are defined as some or total assistance with ADLs (activities such as dressing, bathing, hygiene/grooming, toileting, ambulation/mobility, transferring and eating), and/or IADLs, such as housekeeping, shopping, meal preparation, laundry, transportation and telephone use essential to the maintenance of the participant’s health and welfare in the community. This was also reiterated in Meeting Minutes of the Transition Workgroup Q&A dated February 19, 2016.

CFCO guidelines indicate:

ADL and IADL skill acquisition, maintenance, and enhancement: These services and supports are intended to maximize the consumer’s independence and/or promote integration into the community by addressing the skills needed for the consumer to perform ADLs and IADLs. This service may include assessment, training, supervision, cueing, or hands-on assistance to help a consumer perform specific tasks, including:

• self-care
• life safety
• medication management
• communication
• mobility
• community transportation
• community integration
• inappropriate social behaviors
• money management
• maintaining a household

This service may be time limited, especially when the consumer can be reasonably expected to learn to perform the task(s) independently. However, the duration of assistance may be extended, or the scope may be changed from hands-on assistance to supervision and/or cueing, depending on the assessed need.

Q: Will NYSDOH consider keeping “oversight and supervision” as a discrete service provided through a 1915c waiver?

A: As stated above, this service is included in the State Plan Amendment (SPA) that now provides the service through CFCO.

Q: How will NYSDOH address MCO plan capacity particularly as it is related to sufficient staffing to provide services? This is of particular concern in Upstate NY.

A: The MCO Plan must demonstrate and maintain, to the Department’s satisfaction, a sufficient and adequate network for delivery of all covered services.

The Contractor shall have a minimum of two (2) providers that are accepting new members in each county in its service area for each covered service in the benefit package unless the county has an insufficient number of providers licensed, certified or available in that county as determined by the Department. This is discussed further in the Waiver Transition Plan on page 16, under Plan Readiness.

Q: How will the HCBS settings rule be implemented in relationship to the waiver transition?

A: As explained on page 24 of the Waiver Transition Plan, CMS regulatory requirements for HCBS settings require community based services to be delivered in settings that meet defined criteria. The setting must be integrated and support full access of individuals receiving Medicaid HCBS to the greater community, including opportunities to seek employment and work in competitive integrated settings, engage in community life, control personal resources, and receive services in the community, to the same degree of access as individuals not receiving Medicaid HCBS. CMS also clarifies those settings that do not qualify as “home and community-based settings.” Individuals residing in these non-qualifying settings may not receive community based services.

Settings that do not qualify as “home and community-based settings” per federal regulation include:

• A nursing facility;
• An institution for mental diseases (IMD);
• An intermediate care facility for individuals with intellectual disabilities;
• A hospital; and
• Any other settings that have the qualities of an institutional setting

Q: What assistance is provided to individuals with TBI in navigating the managed care enrollment process?

A: For individuals not receiving services at the time of transition, pursuant to Section 364-j of the Social Services Law, the Department contracts with an “enrollment broker” to provide education, outreach and enrollment services for the Medicaid managed care program. New York Medicaid Choice provides these services additionally, Local Departments of Social Services (LDSS) may assist with this process. This process is explained on page 10 of the Waiver Transition Plan. As explained on page 12 of the Waiver Transition Plan, any waiver participant transitioning to MLTC will be deemed eligible for Community Based Long Term Care (CBLTC) for two years as long as the member actively participates in services identified in the plan of care. The member must receive at least one service at least monthly in order to maintain CBLTC eligibility. Current NHTD/TBI waiver participants effective January 1, 2018, are ensured continuity of care: all services in place at the time of transition will continue for the first six months of the transition period into MLTC/MMC and the member will not be required to go to the Conflict Free Evaluation and Enrollment Center (CFEEC) prior to enrollment into MLTC. All existing services identified in the service plan at the time of enrollment will continue to be provided for at least six months after the member’s enrollment date. After six months of service transition, the plan will reassess the member for specific service needs. Any individual seeking CFCO services at this time must be assessed to confirm the member meets the eligibility criteria for CFCO services. The waiver participant’s Service Coordinator and the Regional Resource Development Center will continue as a support and resource to all waiver participants.

Q: How does the Transition Plan address the needs of individuals placed in out of state placements seeking repatriation to NYS?

A: Individuals residing in out of state placements will continue to receive services as they are currently in place. Repatriation is not a waiver transition issue as these individuals are currently not waiver participants. A separate workgroup established by the TBI Services Coordinating Council is convening to develop recommendations specific to this issue.

Q: Will NYSDOH provide a realistic timeline that addresses procedures for the transition of both waivers to managed care?

A: The current transition period beginning in January 2018 is sufficient to address the transition planning process.

Q: What will NYSDOH do to more actively engage participants and stakeholders in the transition planning process?

A: As indicated on page 17 of the Waiver Transition Plan, as part of the transition process, an extensive training and outreach program will be developed and implemented:

• Education will be involved to address the extended needs of the population.
• Outreach to members will include face-to-face education at the local level and phone support through call centers.
• The New York Medicaid Choice (NYMC) call center has multiple language lines and contracts with a translation company. Additionally, the RRDCs may assist in participant contact and outreach.
• Outreach calls/follow-up assistance calls will continue throughout the timeline of the transition.
• DOH will train NYMC, the Managed Care Plans, and providers to effectively work with these specific populations and each other.

NYSDOH has offered all stakeholders the opportunity to have input to the content of the training when training materials are developed. Additionally, NYSDOH has indicated that the RRDC will continue to have a role in the coordination of services after the transition to managed care. The RRDCs have demonstrated expertise and support when working with the target populations receiving services through the waivers. The RRDCs will serve as technical assistance providers to plans and service recipients.

NYSDOH will conduct a MLTC/MMC plan/provider webinar to inform stakeholders of the transition, as well as to outline network readiness and provider qualification requirements.

Throughout the transition planning process, NYSDOH has maintained a website to specifically provide an opportunity for ongoing public review: http://www.health.ny.gov/health_care/medicaid/redesign/.

Additionally, the site provides information, materials and FAQs on the transition process. A mailbox to address questions specific to the NHTD/TBI 1915c waiver transition process is established at: waivertransition@health.

Q: How will NYSDOH minimize the potential disruption of services once the transition plan is implemented?

A: As indicated on page 12 of the Waiver Transition Plan, NYSDOH is proposing to establish a two (2) year continuity-of-care period for participants and service providers. As a result, MCOs will be required to contract with current waiver service providers for a minimum of two (2) years:

• If the service provider is serving five (5) or more current waiver participants;
• If the service provider continues to serve participants/members unless a health/safety concern exists; and
• As long as the service provider assures that there are appropriately licensed personnel to provide and/or supervise services.

Any waiver participant transitioning to MLTC will be deemed eligible for Community Based Long Term Care (CBLTC) for two (2) years as long as the member actively participates in services identified in the plan of care. The member must receive at least one service at least monthly in order to maintain CBLTC eligibility. Current NHTD/TBI waiver participants, effective January 1, 2018, are ensured continuity of care: all services in place at the time of transition will continue for the first six (6) months of the transition period into MLTC/MMC and the member will not be required to go to the Conflict Free Evaluation and Enrollment Center (CFEEC) prior to enrollment into MLTC. All existing services identified in the service plan at the time of enrollment will continue to be provided for at least six (6) months after the member’s enrollment date. After six (6) months of service transition, the plan will reassess the member for specific service needs. Any individual seeking CFCO services at this time must be assessed to confirm the member meets the eligibility criteria for CFCO services.

Current waiver participants will have the choice to maintain his or her existing providers for up to two (2) years, if his or her needs remain the same after the first six (6) months of service provision and if the providers meet the conditions above.

Q: Why does the transition plan require a six (6) month review/assessment of the individual’s needs every six (6) months rather than yearly?

A: There are several requirements within the service delivery system that establish a six (6) month review. This is a current waiver requirement, a Licensed Home Care Service (LHCSA) requirement and personal care requirement contingent on what services the person is receiving. This requirement ensures protections for the individual to confirm the person’s health and safety as well as continued service needs.

Q: How will NYSDOH oversee quality of care over the plans?

A: As indicated on page 22 of the Waiver Transition Plan, NYSDOH has strong quality assurance(s) in place for all Managed Care Organizations. Each managed care plan must have a quality assurance and performance improvement program that includes a health information system consistent with the requirements of 42 CFR § 438.242, and a NYSDOH approved written quality plan for ongoing assessment, implementation and evaluation of overall quality of care and services. The plan will include goals and objectives that provide a framework for quality assurance and improvement activities, evaluation and corrective action. These goals and objectives should be reviewed and revised periodically, and should be supported by data collection activities that focus on clinical and functional outcomes, encounter and utilization data, and client satisfaction data. Plans that do not meet certain thresholds will not receive quality payments.

All MCOs and their networks will be measured on meeting basic contract standards, as well as quality metrics. If a plan fails to meet certain metrics, there will be reimbursement implications.

Q: Will NYSDOH consider having service coordinators function as independent entities with a sole responsibility of developing the service plan and providing oversight of service provision?

A: There are no provisions within the Waiver Transition Plan to implement this service as defined above.

Q: Would NYSDOH consider maintaining a 1915c waiver for purposes of providing service coordination to MCO members and CFCO FFS participants?

A: There are currently no plans to continue a 1915c waiver after full implementation of the transition to managed care. 1915c waiver requirements restrict any duplication of care management /case management functions.

Q: Will Service Coordinators be required to provide at least one (1) face to face visit per month in addition to contact provided by the care manager? Can the visit be combined with a visit from the care manager?

A: Page 7 of the Waiver Transition Plan indicates: Service Coordinators will be responsible to complete one (1) face-to-face visit per month per member and at least one (1) home visit every six (6) months per member. The Service Coordination home visit will not coincide with the home visit completed by the Care Manager. This language was developed to ensure maximum case coverage and visits to a member. A team approach to service development/provision is necessary, however this language provides protections to ensure that billing for duplicate services does not occur, noting that the definition of Service Coordination will be different from the definition of Care Management in managed care.

Q: Why must waiver participants go through two (2) administrative processes: one for MLTC/MMC and RRDC review?

A: As indicated on page 7 of the Waiver Transition Plan, The RRDCs will serve as a resource to ensure that the managed care plans and providers have received appropriate training and education related to services and special needs populations. Additionally, the centers will serve as functional assessment and technical assistance centers to members and providers. Any plan member seeking the five (5) enhanced benefits must seek the service through the RRDC and in conjunction with his/her managed care plan. The RRDC will complete a service assessment to establish the need for the service, advise the MCO of the assessment outcome and facilitate in-network provider selection in conjunction with the plan member. The decision to provide the service will be based on need. The role of the RRDC is to supplement and support the care planning initiated and implemented by the Managed Care Organizations. This procedure was included in response to comments provided by the Workgroup who indicated that the RRDCs provided additional expertise and insight related to the needs of the waiver population.

Q: Will Community Transitional Services (CTS) services be expanded to include individuals residing in the community?

A: CTS is currently a waiver service provided only to individuals transitioning from nursing homes and, as such, was incorporated as the comparable service in CFCO. CTS is now included in the CFCO State Plan Amendment (SPA) and the service definition addresses nursing home transitions only.

Q: Are there criteria, or is the Department contemplating developing criteria for determining whether an assistive device or technology increases, maintains, or improves functional abilities?

A: NYSDOH is developing criteria for Assistive Technology, Environmental Modifications, Vehicle Modifications and other CFCO services. CFCO currently defines Assistive Technology as an item, piece of equipment, product system or instrument of technology, whether mechanical or electrical and whether acquired commercially, modified, or customized. The use of the AT must increase a consumer’s independence or substitute for human assistance that would otherwise be authorized (e.g., personal care services). AT does not include items that are covered within the scope of durable medical equipment. Examples of AT include but are not limited to:

• motion/sound, toilet flush, incontinence and fall sensors
• automatic faucet and soap dispensers
• two-way communication systems
• augmentative communication aids and devices
• adaptive aids and devices

Providers of this service will assist the consumer in the selection, acquisition and/or use of the authorized AT. Electronic back-up systems are also included in the definition of AT. Electronic back-up systems are devices that enable a consumer to secure help in an emergency, enhance safety in the community, or provide reminders that will assist the consumer with activities such as medication management, eating or other activities for which monitoring is necessary.

Until waiver services are transitioned to managed care, upon approval by CMS, these services may continue to be provided as “extended state plan services” in the context of the 1915c waiver.

Page 3 of the Waiver Transition Plan indicates: “The service will only be approved when the requested equipment and supplies improve or maintain the member’s level of independence, ability to access needed supports and services in the community or maintain or improve the member’s safety and health.”

Q: RRDCs currently do not provide service assessments. What accommodations will be made to train RRDC staff on how to complete functional assessments and what tool will be used to complete a functional assessment?

A: RRDCs currently provide service assessments during intake meetings, eligibility determinations, PRI/SCREEN/UAS-NY assessments, service plan reviews, team meetings and case conferences. The RRDC contract specifically indicates that the Lead RRDS must have professional experience working with people with disabilities, cognitive deficits and/or seniors. To qualify for the appointment to the Nurse Evaluator position, the individual must have excellent clinical assessment skills and must be able to perform each duty specified in the contract satisfactorily.

Q: Current waiver participants have not been sufficiently notified regarding the waiver transition process. What will NYSDOH do to notify participants and their families of the process and outcome of the Transition Workgroup?

A: As indicated on page 16 of the Waiver Transition Plan, a subcommittee of the larger workgroup met on several occasions to discuss member/participant notifications and provider/plan training. The content of the notices was reviewed by waiver participants in order to ensure clarity of the content and readability by the waiver population at large. Additionally, training topics for New York Medicaid Choice (NYMC) and provider staff were identified. As the transition process moves forward, stakeholders and providers will participate in developing training materials and curricula. NYSDOH anticipates that a significant amount of the training materials currently utilized in the waiver programs will be amended to accommodate the managed care environment.

Q: How will NYSDOH provide guidance to existing waiver providers related to continuity of care issues and what happens after the two (2) year transition period?

A: As indicated on page 17 of the Waiver Transition Plan, NYSDOH will conduct a MLTC/MMC plan/provider webinar to inform stakeholders/providers of the transition, as well as outline network readiness, provider qualification requirements and plans for after the transition period.

Q: Can the qualifications for waiver service providers be amended prior to the implementation of the Transition Plan?

A: Both the NHTD and TBI 1915c waiver applications filed with CMS are in temporary extension. Amendments cannot be made to applications that are in temporary extension.

Q: Can the eligibility of CBLTC be amended to include all waiver services?

A: Currently there are no provisions within the Waiver Transition Plan to include this recommendation. NYSDOH has made a significant effort to include all comparable services that are fully utilized by waiver participants into managed care and ensure that current waiver participants are ensured continuity of care. Page 10 of the Waiver Transition Plan indicates: existing participants of the NHTD/TBI waiver programs effective January 1, 2018, will be deemed eligible for community based long term care (CBLTC) services and will not be required to go to the Conflict-Free Evaluation and Enrollment Center (CFEEC) prior to enrollment into MLTC. Any waiver participant transitioning to MLTC will be deemed eligible for CBLTC for two (2) years as long as the member actively participates in services identified in the plan of care. The member must receive at least one (1) service at least monthly in order to maintain CBLTC eligibility.

Q: Will NYSDOH consider rate increases prior to the transition period to be carried into the two (2) year rate guarantee period?

A: Both the NHTD and TBI 1915c waiver applications filed with CMS are in temporary extension. Amendments cannot be made to applications that are in temporary extension. It continues to be the position of NYSDOH that whatever rates are in place at the time of transition (1/1/18) will be the rate guarantee. This would be the minimum standard for negotiation with the plans.

Q: Is the two (2) year rate guarantee for transition waiver participants only?

A: Yes.

Q: How does Risk Adjusted payment for MCOs work and how would this impact the waiver transition plan? Will a high-needs rate cell be developed to encourage community based services?

A: Questions related to rates will be addressed by a Workgroup sub-committee at a later date. As indicated in the MCO contract, capitation rates will be determined prospectively and will not be retroactively adjusted. Capitated rates will be certified to be actuarially sound in accordance with 42 CFR § 438.6(c).

Individuals with a Medicaid spend down/medically needy are excluded from enrolling in Medicaid Managed Care. The transition plan again does not detail how this will affect current NHTD/TBI waiver participants’ access to services.

Q: Can key protections be afforded for CFCO individuals as similar to waiver participants?

A: This issue is more appropriately addressed by the CFCO Implementation Team.

Q: What actions will NYSDOH take if it is determined that plans are unjustly institutionalizing members of this population that have successfully lived in the community prior to the transition?

A: As established in the Managed Care Plans’ contract, the MCO must provide NYSDOH (on a quarterly basis, and within fifteen (15) business days of the close of the quarter) a summary of all grievance and appeals received during the preceding quarter using a data transmission method that is determined by NYSDOH.

The MCO must also agree to provide on a quarterly basis, within fifteen (15) business days of the close of the quarter, the total number of grievance or appeals that have been unresolved for more than thirty (30) days. The MCO must maintain records on these and other grievances or appeals, which shall include all correspondence related to the grievance or appeal, and an explanation of disposition. These records shall be readily available for review by NYSDOH.

The MCO must submit member health and functional status data for each of its members in the format and according to the timeframes specified by NYSDOH.

The MCO must submit to NYSDOH, within fifteen (15) days of the close of each quarter, a Critical Incident Report, in a format specified by NYSDOH, which includes the following:

• The number of critical incidents that were investigated by the MCO, including the outcome.

The MCO must submit to NYSDOH, within fifteen (15) days of the close of each quarter, a report, in a format specified by NYSDOH, which includes the following:

• The number of individuals who were enrolled in the MLTCP from a nursing home.
• The number of members who were admitted to a nursing home but returned to the community.
• The number of members who were permanently admitted to a nursing home.

Q: Why do SCs have to have a license? Remove all licensure requirements.

A: The MCO must comply with applicable sections of Public Health Law (PHL) and regulations regarding provider contract requirements. The MCO may only enter into contracts with providers who are in compliance with all applicable state and federal licensing, certification, and other requirements; are generally regarded as having a good reputation; and have demonstrated capacity to perform the needed contracted services. As currently established in the waiver programs, Service Coordinators are not required to be licensed; however, Licensed MSWs, Clinical Social Workers, Speech Pathologists, and Occupational Therapists qualify as Service Coordinators.

Q: What is the appeal process related to the RRDC decisions?

A: As indicated on page 7 of the Waiver Transition Plan, the role of the RRDC is to supplement and support the care planning initiated and implemented by the Managed Care Organizations. The person may appeal the RRDC recommendation to his/her Care Manager and ultimately utilize the plan’s grievance process.

Q: Can CDPAS regulations be amended to provide supervision and cueing?

A: This issue is more appropriately addressed by the CFCO Implementation Team.

Q: What is covered under the non-emergent social transportation benefit, including specific examples of transportation, activities and destinations?

A: CFCO defines Social Transportation as transportation to and from non-medical activities such as social gatherings, religious services and other events in the community when the activity is related to the consumer’s functional needs and appropriately authorized in the members Primary Care Service Plan. Transportation modes include, but are not limited to, taxi, subway, livery, bus, and van.

Members may not receive duplicative services within the Medicaid program. All social transportation trips must be supported by the goals identified in the person-centered service plan. Social Transportation services must be approved prior to implementation. The types of trips and destinations must be identified and supported by the service plan. The mode of transportation must support the needs of the individual.

Q: How are managed care providers notified when a member changes a plan, in order to ensure continued payment to the provider?

A: Just as with waiver services, the provider is expected to check eligibility at the time of service. Most health plan changes occur at the beginning of the month. However, providers must continue to ask members if his/her health insurance has changed and require the member to provide his/her most current health plan card.

Q: How do individuals that do not qualify for MLTC services, receive care under Medicaid Managed Care?

A: If an individual is eligible for Medicaid, enrollment into Medicaid Managed Care (MMC) is mandatory unless that individual meets the criteria for an exemption or exclusion. Individuals not meeting the appropriate program criteria may remain as Fee for Service (FFS.)

Q: How are Managed Long Term Care Plans evaluated?

A: The Waiver Transition Plan states: All MCOs and their networks will be measured on meeting basic contract standards as well as quality metrics. If a plan fails to meet certain metrics there will be reimbursement implications. Each health plan is required to develop comprehensive quality assurance monitoring programs, including beneficiary satisfaction surveys, external quality reviews, review of level of care assessments, and the health and welfare of its members. Plans who do not meet certain thresholds will not receive quality payments. Each MLTC undergoes a comprehensive survey every two years. In the off-year, a focused review of the MLTC is conducted as needed. As with comprehensive reviews, an assessment is made to determine if compliance can be measured through a desk audit of if an on-site survey is required.

Q: How will waiver services be accessed in a managed care environment?

A: Just as with waiver services, the plan Care Manager is responsible to develop a person-centered plan of care that identifies the member’s needed services. The Care Manager is responsible to help secure the identified services and to work with the member to arrange for a schedule of service provision. The Transition Workgroup has worked to define current waiver services and cross reference them to services currently available in the managed care plans. This information is available on the Department’s website at: - NHTD/TBI Waiver Transition Information

Q: What are the responsibilities of a Managed Care/Managed Long Term Care Plan?

A: MCO Plans are responsible for providing service authorization for medically needed services. Plan care managers are responsible for the oversight of service planning and service delivery for members, including the development of the person centered service plan. Plans will contract with appropriately credentialed service providers and as appropriate, fiscal intermediaries to make services available to members. The managed care plan is responsible to provide written Notices of Determination (NODs) for the initial authorization, reauthorizations and/or denials of requested services. Plans provide contracted providers with authorization for service provision, including, if applicable, the number of visits per week and duration according to the approved person-centered plan. NYSDOH does not dictate the salaries paid to staff providing services.

Q: Is there a “cap” on the amount of services a person can receive through managed care?

A: NYSDOH does not impose a limit on the services that a managed care plan can provide to an individual. Services are provided based on medical need and are presented in the person-centered plan. If a plan member does not agree with the service plan, they may appeal the decision. As a state plan service, CFCO does impose certain limits on some services; however, with proper approval and based on needs assessments, those limits may be exceeded. Plans have discretion to authorize additional services when determined to be medically necessary. These thresholds do not reset when a member changes plans. Therefore, when a member elects to transfer to another plan, plans will be required to share plan of care information, including information about service utilization. This will help prevent duplication of services and discourage plan-to-plan transfers.

The Waiver Transition Plan states: “The managed care plan contract requires the use of a person centered and directed planning process intended to identify the strengths, capacities and preferences of its members. The service plan identifies the members’ long term care needs and the resources available to meet those needs, and to provide access to additional care options identified by the contract.

The managed care plan contract requires that services be delivered in accordance with the service plan, including the type, scope, amount and frequency of service.”

Q: Are there a sufficient number of plans and providers willing to provide services to waiver participants, when they move to managed care?

A: NYSDOH has provided managed care plans with lists of providers with whom they may contract. Managed Care Plans must contract with a minimum of two providers per county for each service. An exception to this requirement may be allowed if a Plan can document diligent effort to identify service providers and there is only one willing and qualified entity available to provide services in a geographic area, such as in a rural area. Plans will be asked to submit enhanced networks as part of the readiness review process; therefore, plans should begin to contract and develop their networks. NYSDOH continues to monitor plan capacity on an ongoing basis throughout the state. It should be noted that approval of waiver services providers is completed on a regional basis and not every county has an extensive list of service providers.

Q: When will enrollment into managed care be “mandatory” for waiver participants?

A: NHTD/TBI waiver participants will receive an announcement letter on or about December 1, 2017 indicating that voluntary enrollment of existing waiver participants into a managed care product will be effective statewide January 1, 2018 and that the NHTD/TBI waiver programs will no longer be available effective April 1, 2018. If the current waiver participant wants to continue receiving long term care services, he or she must enroll in MLTC or MMC, depending on his/her program eligibility. Waiver participants will have the opportunity to voluntarily enroll into managed care effective January 1, 2018. Individuals required to mandatorily enroll in a managed care product who do not voluntarily enroll by March 1, 2018, will be auto assigned for services, effective April 1, 2018. If he or she is not subject to mandatory enrollment and do not voluntarily enroll into a managed care product by April 1, 2018, waiver services will no longer be available. Participants will be sent a 60-day notice on January 1, 2018, a 30-day notice on February 1, 2018 and, if applicable, an auto assignment letter on March 1, 2018.

Q: What is the role of the Regional Resource Development Center in relationship to the managed care plans?

A: The nine Regional Resource Development Centers (RRDCs) currently contracted to administer the daily operations of the 1915c NHTD and TBI waivers will assist participants as they move to managed care. These efforts will include, but are not limited to, issuing notices, addressing phone calls, offering regional community forums, ensuring transition of services, records retention and ensuring member choice of providers. After the transition period is completed, the RRDCs will serve in a consultative role to the managed care plans by assisting in functional assessments, facilitating training and recommending services. It should be noted, the managed care plan is the only entity authorized to approve services. It is anticipated that NYSDOH will initiate an RFA to continue the role of the RRDCs in a managed care environment in 2017.

Q: How will individuals residing in nursing homes and other health care facilities access managed care services?

A: New York Association of Independent Living (NYAIL) is partnering with Independent Living Centers (ILCs) across the state assist individuals residing in long term care facilities to access community based services. The Open Doors Transition Centers have transition specialists at ILCs across the state to directly assist people in nursing homes access the services they need to return to the community. The transition specialists work with people who are moving to community settings to identify needed services and supports and facilitate necessary referrals in conjunction with facility discharge planners.

Q: How will Structured Day Programs be required to comply with 42 CFR§ 441.530?

A: This issue will not be addressed in the waiver transition plan. States have until March 2019 to meet compliance requirements. NYSDOH continues to work with key stakeholders to develop proposals for statutory and regulatory amendments to ensure compliance with the rule. These amendments are anticipated by January 2019. Comments and questions may be directed to HCBSrule@health.ny.gov.

Q: How will NYSDOH track waiver participants after the transition to managed care?

A: The current Medicaid Management Information System (MMIS) is being re-structured. NYSDOH will work with systems designers to develop a mechanism that will continue to identify current waiver participants as they move into the managed care system.

Q: Can a Service Coordinator be an emergency back-up for a waiver participant, when they are the entity responsible to ensure that providers offer sufficient supervision and safety oversight?

A: There is much discussion about when the role of a Service Coordinator as the entity responsible for the development of the person-centered plan ends and that professional becomes an “advocate” and or ‘informal support” to the individual. It has been the position of NYSDOH since 2013 that the service coordinator/case manager’s role involves assisting the participant in developing the initial and subsequent Service Plans; determining the level, quantity, and frequency of those services; coordinating and monitoring all services and equipment provided in the Service Plan as well as initiating and overseeing the assessment and reassessment of the participant’s level of care and conducting an on-going review of the Service Plan. The Service Coordinator is not to serve as a “substitute” or “replacement” for sufficient family and informal supports that are necessary to help an individual maintain community life. Service Coordinators are employees of approved Medicaid enrolled provider agencies and may not exceed their approved authority and exceed their role as providers reimbursed through the Medicaid system.