Preliminary. LTHHCP Issues, Concerns and Recommendations For Discussion with NYS Department of Health At HCA Statewide LTHHCP Forum (Updated 3/4/13)

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1 1 Preliminary LTHHCP Issues, Concerns and Recommendations For Discussion with NYS Department of Health At HCA Statewide LTHHCP Forum (Updated 3/4/13) March 7, 2013 Hotel Albany, Albany NY LTHHCP Role, Structure, Continuity 1. Request: When under contract with managed care, maintain LTHHCP structure, services, staffing, certification, etc., (except for LDSS involvement of course, which is replaced by the MLTC), but conform patient eligibility and operating regulations to MLTC via HCA regulatory realignment proposal. 2. Request: LTHHCPs, CHHAs, LHCSAs and MCOs/MLTCs need regulatory compatibility, clarity and efficiency under the managed care environment, including areas such as assessment, assessment frequency, supervision frequency, procurement of medical orders, and similar. HCA has submitted to DOH a regulatory realignment proposal to accomplish these purposes and urges adoption of the realignment proposal. The proposal is critical. Also, specifically, for LTHHCP, additional regulatory and operational compatibility should include, under managed care: No requirement for patient budgets. No LTHHCP cap applicability. The MCO/MLTC home and community based services need standards, not the nursing home eligibility standard. No slot limitations No need for the DMS-1 or Home Assessment Abstract, only the SAAM Without regulatory realignment and uniformity, providers express further concern regarding the potential for multiple agencies to be caring for the same patient, all with differing, overlapping and potentially conflicting rules and requirements. 3. Request: Please confirm to MCOs, MLTCs, consumers and other stakeholders that LTHHCPs are not affected in their authorization to directly admit, care and bill for Medicare and private/ third-party pay patients. 4. Question: If the LTHHCP enters a contract as a service provider for an MLTC, can the LTHHCP continue to subcontract for services with a LHCSA (e.g. PCA/HHA) the way LTHHCPs do now if the MLTC agrees with such an arrangement?

2 2 5. Question: If the 1115 or 1915-c waiver amendments are not approved to close direct access to LTHHCP, will enrollment in MLTCP and LTHHCP be options for the consumer based on his/her needs? 6. Request: Reconsider the 1915-c waiver amendment and maintain the LTHHCP as an intact program option alongside managed care. LTHHCP Access, Continuity of Care and Patient Choice Issues 1. Question: How is the choice of LTHHCP as a distinct option to managed care or other options being ensured now under terms and conditions CMS issued in its August 2012 approval of the mandatory enrollment amendment that maintains LTHHCP outside of managed care? 2. Question: How will choice of program/provider (including LTHHCP) be made available to the patient when transitioning to, newly enrolling in or renewing enrollment in MCO/MLTC? Will the clients in the communities be given a list of LTHHCP they could sign up with, as they are getting a list of MLTC from the brokers? LTHHCPs have seen the sample letter, and the LTHHCPs are not included. In the near future as LTHHCP clients are signed up with a MLTC, how will the plan communicate as to retaining LTHHCP services or discharging them? 3. Request: Continuity of care for LTHHCP patients currently receiving services should be equitable to continuity of care protection currently being provided, and recently extended for, home attendant/personal care, including contracting and payment requirements. 4. Clarification: DOH should clarify that new cases have access to LTHHCP for services prior to MLTC enrollment if advance services are necessary to ensure safe and adequate care of an individual. 5. Question: What standards does the Department have in mind for network adequacy for participating LTHHCPs in an MLTC or MCO? 6. Question: What standards does the Department have in mind for adequacy of MCOs/MLTCs in a region? 7. Request: Providers have reported it to be a challenge to reach personnel in health plans after 5 pm. Access to plan contacts is essential. Similar to provisions included in the DOH Care Management Service Agreements, plans should be required to have identified contact(s) for providers for resolution of issues, and contact should be accessible on a continuous basis. Home Telehealth Request: In order to avoid unnecessary and potentially harmful disruption in Telehealth services, the Home Telehealth Program should be continued under the provisions of Public Health Section c, and any addition of Home Telehealth to MCO or MLTC should be provided and reimbursed pursuant to c.

3 3 Eligibility, Due Process and Authorization Issues 1. Question: Who will be required to perform patient assessments? 2. Request: Given that DOH is attempting to implement the Uniform Assessment System to replace the SAAM, the Home Assessment Abstract and DMS-1, DOH should request federal waiver so that UAS also replaces OASIS, rather than maintain such duplication. 3. Questions: Are UAS/SAAMs considered skilled care for LTHHCP or LCHSAs? Or will this be like a PRI? - No MD orders required? 4. Question: What assessment instruments will be required for Medicare and/or private pay persons on LTHHCP, especially as DMS-1 is being eliminated? 5. Request: Due process and appeal rights, including aid continuing, for LTHHCPs and patients should include at least the same protections as apply now. 6. Question: Who will be determining patient eligibility for MLTC? How will the selection/referral process take place? 7. Question: What are the service obligations of the provider when the plan no longer authorizes care, or reduces or changes care? 8. Question: Who is responsible for paying for/absorbing the cost of care for Aid Continuing when the decisions go against the patient? 9. Question: Spousal Budgeting is currently not available under MLTC as it is under LTHHCP. Patients will lose eligibility and services if transferred to MLTC without these same protections. What is planned to avoid patients loss of eligibility and services? If enrolled in LTHHCP under contract with MLTCs or MCOs, can patients retain spousal budgeting protection? 10. Question: The experience of existing home care agencies contracting with managed care/mltc is revealing that in some cases patient eligibility, even if verified on one day, may be lost, or patients may switch plans, without notice to the provider, or may have been mistakenly indicated in the first instance, sometimes resulting in months of retroactive eligibility loss. Who is responsible for verifying eligibility the provider or the plan and who bears financial liability when services are provided to patients subsequently deemed ineligible? 11. Issue: Providers are completing M-11V s for patients to go to MLTC but have a problem in Altracs when the 180 day is due. Providers can do one or the other, but that becomes a problem if the patient s 180 day authorization expires, especially if the patient isn t enrolled on the first of the next month. This is only an issue because of Altracs. Providers are being penalized because of the computer system.

4 4 12. Issue: For some patients it is taking a long time for the Code 30 to be removed so it is taking up to 60 days to transfer a patient to MLTC. It is requiring multiple discharge date changes on the M-11V. One provider cited a patient who signed up with MLTC in January and still isn't enrolled. These are issues that must be addressed, and show why some of the earlier questions and requests regarding access to and payment of LTHHCP for those not or not yet enrolled in MLTC/MCO are important. 13. Question: What will be the process for identifying those patients who presently have "code 30"? Our concern is that they will be deferred from Maximus if the code remains, and the patient will be left without service due to the submission of the M11-V 14. Question: How will the MLTCPs be handling the LTHHCP patients who have a Medicaid surplus? Payment/Reimbursement 1. Question: Will LTHHCPs be reimbursed fee-for-service, episodic or other manner for patients referred for service and able to be cared for LTHHCPs when these patients are not (or not yet) enrolled in MLTC or other managed care? 2. Question: What requirements are DOH including in state/health plan and in health plan/provider contract terms to ensure adequate payment for LTHHCP services, personnel, wage parity, and essential infrastructure? Request that DOH ensure adequate premium to MCOs/MLTCs to, in turn, ensure adequate payment to LTHHCPs and other providers for services, personnel, etc. 3. Request: LTHHCPs in wage parity regions have had no adjustment to their rates to enable providers to meet wage parity obligations. Unlike MLTCs or MCOs, which are paid in the aggregate (PMPM), and the DOH rate structure for LTHHCPs is service-specific, not according the same level of flexibility. LTHHCP rates in wage parity regions require adjustment in order to implement this policy during the MLTC transition period and beyond. Surveillance/Compliance 1. Question: How will surveillance change under MCO/MLTC, especially for providers who are handling only a portion of the care/care plan for the patient? 2. Request: Regulatory, patient care and operational responsibilities must be sorted out and clarified in terms of the roles and responsibilities of LTHHCPs and MCOs/MLTCs. This must be accomplished prior to enrollments, transfers, etc. The HCA legislative proposal for regulatory realignment seeks to address this issue through the recommendations of a technical provider, health plan, DOH panel. 3. Question: Will DOH issue a DAL on the DOH survey standards/requirements for case management services? There is limited language in DAL of Feb No agency knows how this will be surveyed.

5 5 4. Question: How is surveillance, compliance, liability affected when care management, assessment, services, authorizations and other functions are split across providers and plans? Information, Education and Assistance 1. Request: MCOs and MLTCs need education on LTHHCP what is it.. how it works strengths the fact that all forms of contracts (services, care management, etc) are permissible. etc. 2. Request: Chart the differences in eligibility, procedure, services and contracting between mainstream managed care and MLTC. 3. Request: Describe the forms and contracts required for the different partner arrangements with MCOs or MLTCs that cover assessment, direct services, care management and/or other. 4. Request: LTHHCPs, plans and patients will need technical assistance and a reasonable timetable for transition. 5. Question: How do the staffing requirements of the MLTC compare to the staffing of the LTHHCP? Timeline & Other 1. Question: How will the mandatory enrollment of LTHHCP patients be rolled out? Is there a time frame for LTHHCPs to roll these patients into MLTCPs? 2. Question: Will LHCSAs be able to do case management services for MLTCs? Is there a specific already published DAL number for this? Is this a service that needs MD orders? 3. Question: What adjustments will be made for the differences upstate vs downstate? There are significant challenges faced upstate that make the move to MLTCP particularly challenging. For example the cost of aide service is higher upstate and the shortage of available aides is concerning. 4. Question: What are the guidelines for disclosing to current LTHHCP patients and/or potential MLTC members the relationships that exist between the plans and the providers? Providers had originally been told that they could not put in writing which plans they are working with but they could tell patients verbally. It seems that some plans and providers have told potential members that in order to keep their current services they need to sign up with a particular MLTC. This needs further clarification. Can a LTHHCP list in their program brochure the MLTCs and other managed care plans for which the LTHHCP is a network provider? 5. Question: If an MLTC is contracting with an LTHHCP to be a delegated care manager, may/must this relationship be disclosed to the public and/or potential members? Can there be co-branding by both entities?