MANAGED LONG-TERM CARE: ISSUES IN 2016

Transcription

1 EVELYN FRANK LEGAL RESOURCES PROGRAM MANAGED LONG-TERM CARE: ISSUES IN 2016 APPENDIX A. Materials on Immediate Need Personal Care Services a. NYC HRA Medicaid Alert Oct. 19, b. Attestation of Immediate Need Form NYS OHIP c. IMMEDIATE NEED TRANSMITTAL TO THE HOME CARE SERVICES PROGRAM...7 d. Spousal Budgeting Assessment Request Form (can also be used with MLTC after application... 8 B. Materials on FIDA & MLTC & Hearings a. NYC HRA Form Notice to All MLTC Members about FIDA 10/ b. MLTC and FIDA plan lists c. Form for requesting MLTC plan documens for Fair Hearing prep C. ICAN 1. ICAN Brochure Independent Consumer Advocacy Network State Sponsored Ombudsprogram for MLC and FIDA, and Mainstream Managed Care issues regarding long term care services... 17

2 Medical Insurance and Community Services Administration (MICSA) MEDICAID ALERT Immediate Need for Personal Care or Consumer Directed Personal Assistance Services The purpose of this Alert is to inform Medicaid providers, community based organizations and others assisting Medicaid clients of the procedure for requesting Immediate Need Personal Care or Consumer Directed Personal Assistance Services. I. Consumer with Immediate Need for Home Care Services In order to be considered a consumer with an Immediate Need for Home Care Services, the consumer must meet the following conditions: a. Have an immediate need for Personal Care or Consumer Directed Personal Assistance Services; b. Have no informal caregivers available, able or willing to provide personal care services; c. Have no home care agency providing needed assistance; d. Does not have third party insurance or Medicare benefits available to pay for needed assistance; e. Does not have adaptive or specialized equipment or supplies in use to meet, or has adaptive or specialized equipment or supplies that cannot meet, the person s need for assistance. A consumer must attest to meeting these conditions by completing and signing the OHIP-0103, Immediate Need for Personal Care Services/Consumer Directed Personal Care Services: Informational Notice and Attestation Form. II. Submission of an Immediate Needs Request A new transmittal, HCSP-3052, Immediate Need Transmittal to the Home Care Services Program has been developed to facilitate Immediate Needs Requests. Required documents vary depending on whether or not the consumer is already in receipt of Medicaid with coverage for long term care, needs NYC Medicaid Alerts are a Periodic Service of the NYC Human Resources Administration Medical Assistance Program Office of Eligibility Information Services 785 Atlantic Avenue, Brooklyn, NY Steven Banks, Commissioner Karen Lane, Executive Deputy Commissioner Maria Ortiz-Quezada, Director of EIS Copyright 2016 The City of New York, Department of Social Services. For permission to reproduce all or part of this material contact the New York City Human Resources Administration. -1-

3 NYC MEDICAID ALERT Page 2 to upgrade their Medicaid coverage to include long term care or needs to apply for Medicaid. These requirements are detailed on the transmittal. A. Documents to be Submitted All consumers: 1) Attestation of Immediate Need (OHIP- 0103); 2) Medical Request for Home Care (HCSP-M11q). If the M-11q is not readily available a physician s order may be submitted for purposes of determining if the consumer has an immediate need for an expedited Medicaid eligibility determination. A M-11q is required to begin the expedited immediate need home care service assessment and determination; 3) Authorization for Release of Health Information Pursuant to HIPAA (OCA-960). This is needed to be able to discuss case with person(s) other than the client) 4) Optional (but strongly recommended) A cover letter that includes an explanation of the immediate need, the status of consumer s current whereabouts, a listing of submitted documents, the type of service requested (PCS or CDPAS), etc. Consumers with active Medicaid coverage that needs to be upgraded to include community based long term care, also must submit: 1) A completed Access NY Supplement A (DOH-4495A)* * Note: For purposes of the eligibility determination, a consumer who would otherwise be required to document his or her accumulated resources may attest to the current value of any real property and to the current dollar amount of any bank accounts. Consumers without active Medicaid also must submit: 1) A completed Access NY Insurance Application (DOH-4220) 2) A completed Access NY Supplement A (DOH 4495A)* * Note: For purposes of the eligibility determination, a consumer who would otherwise be required to document his or her accumulated resources may attest to the current value of any real property and to the current dollar amount of any bank accounts. Consumers with Medicaid coverage on the Health Exchange (NY State of Health): The consumer/representative must contact NY State of Health ( or via (hxfacility@health.ny.us) to have the Medicaid transferred to HRA. For these consumers the OHIP-0103, Immediate Need for Personal Care Services/Consumer Directed Personal Care Services: Informational Notice and Attestation Form and the M-11Q, Medical Request for Home Care or physician s order for personal care, must be sent to HRA. -2-

4 NYC MEDICAID ALERT Page 3 Where to Submit 1) Mail to: HRA HCSP Attention: Immediate Needs Liaison 785 Atlantic Avenue, 7 th Floor Brooklyn, New York ) Deliver to: HRA HCSP Attention: Immediate Needs Liaison 785 Atlantic Avenue, 7 th Floor Brooklyn, New York ) efax to: III. Processing of Immediate Needs Cases: The Immediate Need Request packages are logged in and date stamped to establish date of receipt. The expedited processing begins the first calendar day after receipt of the documents. The first calendar day will be referred to as day one (1). Medicaid Determination 1. Within four (4) calendar days after day one (1), the HCSP Medicaid Eligibility Unit (MEU) will review the submitted documents for completeness to determine if a Medicaid eligibility review can proceed. a. If review of the Medicaid Application, Supplement A and supporting documents determines that the package is incomplete, a written notice will be sent to the applicant explaining that the Medicaid processing is deferred. The notice will state what information and/or supporting documents are missing. It will also provide a response due date. b. If the Medicaid Application and Supplement A are determined to be complete and all of the required supporting documents are submitted, a Medicaid determination will be made by the seventh day (7 th ) calendar day after day one (1). Service Authorization Review 1. On day one (1), the Medical Request for Home Care (M11-q) and cover letter, if applicable, will be scanned and registered in the Long Term Care Web (LTCW) system and reviewed for completeness, accuracy and compliance with NYSDOH regulations. 2. Concurrently, the process of scheduling a home visit will be initiated upon verification of a complete Medicaid Application or conversion request for Medicaid with coverage for Long Term Care. -3-

5 NYC MEDICAID ALERT Page 4 3. If the HCSP-M11q is found to be complete, accurate and compliant with regulations, a home visit with the applicant will be scheduled. The service authorization review will be completed prior to the twelfth (12 th ) day from day four. 4. If the HCSP-M11q is found to be incomplete, not accurate or non-compliant with regulations, it will be rejected. A written notice will be sent to the applicant / family / representative stating the reason for the HCSP M11q s rejection. A new Immediate Need request can be submitted with a Attestation form and properly completed M11-q 5. If the applicant is approved for services, the case will be assigned by the 12 th day from day four to a HRA contracted License Home Care Services Agency or Fiscal Intermediary as appropriate. 6. If the applicant is not approved for services, a written notice will be sent to the applicant / representative indicating the reason for denial of services. More information is available in the New York State Department of Health s ADM: 16 OHIP/ADM-02 Immediate Need for Personal Care Service and Consumer Directed Personal Assistance Services. Please note that in addition to posting the new transmittal (HCSP-3052) and OHIP forms on MARC, these forms have also been added to HRA s internet site (Long Term Care) page ( to help ensure these forms are readily available.. PLEASE SHARE THIS ALERT WITH ALL APPROPRIATE STAFF -4-

6 IMMEDIATE NEED FOR PERSONAL CARE SERVICES/CONSUMER DIRECTED PERSONAL ASSISTANCE SERVICES: INFORMATIONAL NOTICE AND ATTESTATION FORM If you think you have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), such as housekeeping, meal preparation, bathing, or toileting, your eligibility for these services may be processed more quickly if you meet the following conditions: You have no informal caregivers available, able and willing to provide or continue to provide care; You are not receiving needed help from a home care services agency; You have no adaptive or specialized equipment or supplies in use to meet your needs; and You have no third party insurance or Medicare benefits available to pay for needed help. If you don t already have Medicaid coverage, and you meet the above conditions, you may ask to have your Medicaid application processed more quickly by sending in: a completed Access NY Health Insurance Application (DOH-4220); the Access NY Supplement A (DOH-4495A or DOH-5178A), if needed; a physician s order for services; and a signed * Attestation of Immediate Need. If you already have Medicaid coverage that does not include coverage for community-based long term care services, you must send in a completed Access NY Supplement A (DOH-4495A or DOH- 5178A), a physician s order for services and a signed * Attestation of Immediate Need. If you already have Medicaid coverage that includes coverage for community-based long term care services, you must send in a physician s order for services and a signed * Attestation of Immediate Need. If you don t already have Medicaid coverage or you have Medicaid coverage that does not include coverage for community-based long term care services: All of the required forms (see the appropriate list, above) must be sent in to your local social services office or, if you live in NYC, to the Human Resources Administration (HRA). As soon as possible after receiving all of these forms, the social services office/hra will then check to make sure that you have sent in all the information necessary to determine your Medicaid eligibility. If more information is needed, they must send you a letter, by no later than four days after receiving these required forms, to request the missing information. This letter will tell you what documents or information you need to send in and the date by which you must send it. By no later than 7 days after the social service office/hra receives the necessary information, they must let you know if you are eligible for Medicaid. By no later than 12 days after receiving all the necessary information, the social services office/hra will also determine whether you could get PCS or CDPAS if you are found eligible for Medicaid. You cannot get this home care from Medicaid unless you are found eligible for Medicaid. If you are found eligible for Medicaid and PCS or CDPAS, the social services office/hra will let you know and you will get the home care as quickly as possible. If you already have Medicaid coverage that includes coverage for community-based long term care services: The physician s order and the signed Attestation of Immediate Need must be sent to your local social services office or HRA. By no later than 12 days after receiving these required forms, the social services office/hra will determine whether you can get PCS or CDPAS. If you are found eligible for PCS or CDPAS, the social services official/hra will let you know and you will get the home care as quickly as possible. The necessary forms may be obtained from your local department of social services or are available to be printed from the Department of Health s website at: *Found on the back side of this page. New York State Department of Health OHIP

7 Attestation of Immediate Need for Personal Care Services/Consumer Directed Personal Assistance Services I, attest that I am in need of immediate Personal Care Services (Name) or Consumer Directed Personal Assistance Services. I also attest that: no voluntary informal caregivers are available, able and willing to provide or continue to provide needed assistance to me; no home care services agency is providing needed assistance to me; adaptive or specialized equipment or supplies including but not limited to bedside commodes, urinals, walkers or wheelchairs, are not in use to meet, or cannot meet, my need for assistance; and third party insurance or Medicare benefits are not available to pay for needed assistance. I certify that the information on this form is correct and complete to the best of my knowledge. X SIGNATURE OF APPLICANT/ REPRESENTATIVE DATE SIGNED Individuals Receiving Long Term Care Services in a Nursing Home or Hospital Setting If you are receiving long term care services in a nursing home or a hospital setting and intend to return home, you may have your eligibility for Personal Care Services or Consumer Directed Personal Assistance Services processed more quickly. Follow the directions on the previous page and fill in the information requested below. I am in a nursing home or a hospital setting and have a date set to return home on. DATE Contact me or my legal representative by calling. New York State Department of Health OHIP

8 IMMEDIATE NEED TRANSMITTAL TO THE HOME CARE SERVICES PROGRAM HCSP-3052 (E) 09/19/2016 DATE: CONSUMER S NAME: LAST 4 DIGITS OF CONSUMER S SSN: From NAME OF SUBMIITING ORGANIZATION STREET ADDRESS CITY, STATE, ZIP CODE To: HOME CARE SERVICES PROGRAM IMMEDIATE NEEDS 785 ATLANTIC AVENUE, 7 th Floor BROOKLYN, NY I am submitting this application package on behalf of the above named consumer for processing as an Immediate Need for home care services. S/he wishes to be enrolled in the following program (check one): Personal Care (PCS) Consumer Directed Personal Assistance (CDPAS) I understand that the documentation listed in the table(s) below is required for this request to be processed. All are attached and appear to be fully completed. For all Immediate Need Requests OHIP-0103, Attestation of Immediate Need HCSP M-11q, Medical Request for Home Care OCA-960, Authorization for Release of Health Information Pursuant to HIPAA Also required, in addition to the three items listed above, if the consumer already has Medicaid coverage, but it does not include long term care coverage DOH-4495A, Access NY Supplement A All necessary proofs that apply to this supplemental form only, as detailed in the DOH-4220 Documents Needed When You Apply For Public Health Insurance section Also, required in addition to everything listed in both tables above, if the consumer does not already have Medicaid coverage at all DOH-4220, Access NY Insurance Application All necessary proofs as detailed in the DOH-4220 Documents Needed When You Apply For Public Health Insurance section Though not required, I understand that submission of a cover letter that includes an explanation of the immediate need, the status of consumer s current whereabouts, a listing of submitted documents, the type of service requested (PCS or CDPAS), is strongly recommended. I have attached a cover letter I have not submitted a cover letter Print Name: Sign Name: Telephone Number: -7-

9 Date: Request for Assessment Form Institutionalized Spouse s Name: Address: Telephone Number: Community Spouse s Name: Current Address: Telephone Number: I/we request an assessment of the items checked below: [ ] Couple s countable resources and the community spouse resource allowance [ ] Community spouse monthly income allowance [ ] Family member allowance(s) Check [ ] if you are a representative acting on behalf of either spouse. Please call your local department of social services if we do not contact you within 10 days of this request. NOTE: If an assessment is requested without a Medicaid application, the local department of social services may charge up to $25 for the cost of preparing and copying the assessment and documentation. Signature of Requesting Individual Address and telephone # if different from above Page 18 March 2014 New York State Medicaid Update -8-9 P a g e

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11 New York City Plan List New York City MLTC Medicaid Plans What services will these Plans provide? n Medicaid home care and other long term care services, including: personal care (home attendants), home health aides, adult day health care, consumer directed personal assistance services, dental care, transportation, and other services. n No Medicare services. n What else should I know? You can keep seeing your Medicare or Medicare Advantage doctor and other providers of services not covered by the Plan. MLTC Medicaid Plans Aetna Better Health AgeWell New York AlphaCare of New York, Inc. ArchCare Community Life Centerlight Healthcare Select MLTC Centers Plan for Healthy Living Contact TTY: TTY: TTY: Service Area Brooklyn, Queens, Manhattan Queens, Manhattan Queens, Manhattan Empire BlueCross BlueShield HealthPlus TTY medicaidmedicare Turn this page -10- PAGE 1 MLTC-MED-PL-E-1115

12 MLTC Medicaid Plans Extended MLTC Fidelis Care at Home GuildNet HomeFirst, a product of Elderplan Independence Care System Integra MLTC, Inc. MetroPlus Managed Long Term Care Montefiore Diamond Care North Shore-LIJ Health Plan, Inc. RiverSpring at Home Senior Health Partners A Healthfirst Company Contact TTY: TTY: TTY: TTY: healthplans-medicaid TTY: TTY: TTY: Service Area Queens, Manhattan Queens, Manhattan Bronx Brooklyn, Queens, Manhattan, Questions? MLTC or (TTY: ) New York Medicaid Choice -11- PAGE 2 MLTC-MED-PL-E1115

13 MLTC Medicaid Plans Senior Whole Health of New York MLTC UnitedHealthcare Personal Assist VillageCareMAX VNSNY CHOICE Managed Long Term Care WellCare Advocate MLTC Contact TTY: TTY: Service Area Queens, Manhattan Queens, Manhattan Questions? MLTC or (TTY: ) New York Medicaid Choice -12- PAGE 3 MLTC-MED-PL-E-1115

14 FIDA Fully Integrated Duals Advantage New York City Plan List What is the FIDA Program? FIDA is a new program that gives you all your Medicare and Medicaid benefits like doctor and hospital visits, medicines, home care, behavioral health care, and nursing home care in one managed care plan. No more multiple plan ID cards! To get your benefits with FIDA, you will use one member ID card. In addition, you will have other benefits like your care team who will work for you to make sure you get your services, get to your appointments, and get your medicine. You will not have to pay anything to your FIDA plan no plan premiums, no deductibles, and no copayments. FIDA plans are managed care plans in the FIDA program. When you join a FIDA plan you are also part of the FIDA program. The FIDA Program is a partnership of New York State Medicaid and the Medicare Program. You may call all the FIDA plans below from 8:00 am to 8:00 pm, seven days a week. Contact Service Area Aetna Better Health FIDA Brooklyn, Manhattan, Queens aetnabetterhealth.com/ny AgeWell New York FIDA Brooklyn, Bronx, TTY: Manhattan, Queens agewellnewyork.com Centers Plan for FIDA Care Complete TTY: Manhattan, Queens, centersplan.com/fida/participants Elderplan FIDA Total Care Manhattan, Queens, elderplanfida.org Fidelis Care FIDA Plan TTY: Manhattan, Queens, fideliscare.org Turn this page PAGE 1-13-

15 FIDA Plans New York City Contact Service Area GuildNet Gold Plus FIDA TTY: Manhattan, Queens, guildnetny.org Healthfirst AbsoluteCare FIDA Manhattan, Queens, healthfirst.org/mmp ICS Community Care Plus FIDA MMP Manhattan, Queens (Independence Care System) icsny.org/care-plus MetroPlus FIDA Plan Manhattan, Queens metroplus.org/fida North Shore-LIJ FIDA Brooklyn, Live Well Manhattan, Queens, NSLIJHealthPlans.com/FIDALiveWell RiverSpring FIDA Plan (affiliated with ElderServe TTY: Manhattan, Queens, Health, Inc.) riverspringfida.org Senior Whole Health FIDA Manhattan, Queens seniorwholehealth.com/fida VillageCareMAX Full Advantage FIDA Plan Manhattan, Queens villagecaremax.org VNSNY Choice FIDA Complete Manhattan, Queens, vnsnychoice.org QUESTIONS? TTY: PAGE 2 FIDA Plan List-NYC-E-0916

16 Request For Fair Hearing Evidence Packet and Specifically Identified Documents Date: MEMBER NAME Fair Hearing Number: Case Number DOB Address: To: Address: [PLAN] - Fair Hearing Liaison Fax #: Tele: PLEASE SEND, FAX, or DOCUMENTS TO: NAME ADDRESS: ATTN: FAX Pursuant to New York State regulations i, please mail, or fax to the person listed above, within five days of this request: (a) copies of all documents the Plan will present at above fair hearing, and (b) copies of the documents listed in (c) below for the period from: Member s initial enrollment with the plan to present date, OR From DATE through the present date, (c) 1. all documents related to assessment for and authorization of personal care, home health aide/chha services, CDPAP, PERS, adult day health care, and any other long-term care services, including all SAAM or Uniform Assessments, nursing assessments, case management records, authorizations, plans of care, and Notices. 2. All records of the licensed home care agency(ies) that have provided member s home care; 3. All signed enrollment forms and disenrollment forms or other documents pertaining to enrollment or disenrollment; 4. All correspondence or records of phone calls, faxes or s with member s doctors, the home care agency providing services, the State Dept. of Health, or with any other person regarding member s services, or eligibility, or need for services. 5. If member received services from HRA CASA Home Care Services -15-

17 Program (personal care or CDPAP), a certified home health agency, a Lombardi Program, or any other home care program, any documents received from that program or pertaining to the last authorization of services from that program. THANK YOU. [Name], [Title] ORGANIZATION ADDRESS New York, NY ZIP TEL: FAX: [ ] i 18 N.Y.C.R.R (b)(1), (2); 18 N.Y.C.R.R (b) -16-

18 What do we do? Toll-Free Helpline Anyone can call our toll-free telephone number to reach a live, expert health counselor. You can get accurate, in-depth guidance on your first call. One-on-One Assistance Through our helpline or our network of agencies, we provide direct assistance to hundreds of people each month. Our cases range from quick advice calls to formal appeals. Community Presentations We educate consumers, advocates and health care providers about Managed Long Term Care and FIDA. Our Services Are Free Get help today. Call: (844) Our helpline is open Monday through Friday, 8am to 8pm. If you are hearing or speech impaired, you can use the NY Relay service by dialing ican@cssny.org Website: icannys.org ICAN is a program of the Community Service Society, and is funded by the State of New York. 633 Third Ave New York, NY (212) cssny.org Get help with Managed Long Term Care ICAN is an independent, free, and confidential resource to help you make the health insurance decisions that are right for you ICAN Brochure, 8/2015

19 What is ICAN? ICAN is a statewide network of organizations Who Does ICAN Help? ICAN is the New York State Ombudsprogram for people with Medicaid who need long term care services. We assist New Yorkers with enrolling in and using managed care plans that cover long term care services, such as home attendant services or nursing home care. We can help you by: Answering questions about Medicaid, Medicare, long term care, and managed care plans Giving you information about your health insurance options, like the new FIDA program, and helping you decide what is right for you Solving problems with your managed care plan or providers, using negotiation or formal appeal processes CSS Center for Independence of the Disabled, NY The Legal Aid Society Medicare Rights Center NY Legal Assistance Group Nassau/Suffolk Law Services Comm. 3. Westchester Disabled On the Move 4. Legal Assistance of Western NY 5. Neighborhood Legal Services 6. Empire Justice Center 7. ACR Health 8. Action for Older Persons 9. Southern Adirondack Independent Living Center 10.Legal Services of the Hudson Valley We help anyone in a Medicaid managed care plan who needs long term care services (like a home attendant or nursing home). We also help people who are applying for Medicaid and need help enrolling in a Managed Long Term Care (MLTC), Medicaid Managed Care (MMC), or Fully Integrated Duals Advantage (FIDA) plan. We can talk with you, your family member, or anyone who is helping you with your health insurance or care decisions. Call ICAN at (844) or visit icannys.org