FAQ 11/15/2017 CAH I/II Webinar

1. What is the required score for CAH II?

Appendix B-6 Evaluation/Reevaluation of the approved 1915c waiver application establishes that children seeking CAH I/II waiver services after April 1, 2017, must have an initial level of care evaluation completed prior to the approved enrollment date for community based individuals using the Pediatric Uniform Assessment System NY (UAS-NY). The Pediatric Patient Review Instrument (PPRI) will be used to determine level of care only when the applicant is being cared for in an institutional setting (hospital/nursing home) or if the Pediatric UAS-NY may not be secured in a timely manner. The UAS-NY must be completed within 90 days of waiver eligibility or the completed PPRI. The assessment established a score of 5 or greater as meeting the criteria for Nursing Facility Level of Care (NFLOC).

For existing CAH I/II waiver participants, LOC assessment is required annually in conjunction with the service plan review or at any time the participant experiences a significant change of condition. If a Pediatric UAS-NY was conducted within 90 days of reassessment due date, and achieved a score of 5 or greater on the Level of Care (LOC) assessment, the reassessment is due one (1) year from the completion of the most recent Pediatric UAS-NY

2. What documentation is required to be contained in the participant's Plan of Care (POC)?

The participants POC should contain the following documents:

  • Home Assessment Abstract (HAA), Form LDSS-3139 - The HAA is completed annually, and reviewed every six (6) months;
  • Level of Care assessment tool as designated by NYSDOH - A new assessment must be completed every year and reviewed every six (6) months. This assessment must be completed by a NYS registered professional nurse who has completed the required training in the assessment process/tool, and is used to assess the child's level of care- hospital or SNF;
  • Physicians Orders - Must be renewed every 60 days. The CAH I/II Case Manager is responsible for assisting families in obtaining needed physician orders. Written and signed physician orders are necessary to obtain nursing, therapy services, palliative care services and home and vehicle modifications;
  • Case Management Plan of Services/ Service Plan - Based on assessment, an individual written Service Plan shall be developed by or on behalf of the LDSS/HRA. The care included shall be consistent with the Level of Care determined necessary by the assessment. The Service Plan must be completed within forty-five (45) days of the date of referral. This timeframe may be waived at the department's discretion. Any variance from this 45-day requirement must be specified and agreed to by the LDSS/HRA.
  • Budget - To ensure that children can be cared for in the community at no greater cost than in the appropriate institutional setting, the child's CAH I/II Case Manager must prepare a monthly budget. The computation of the monthly budget should include all the child's medical expenditures, with the exception of inpatient institutional services (inpatient hospital or SNF).

3. What is required for the six-month review of the Plan of Care (POC)?

Although most of the documentation that makes up the Plan of Care is due annually, it is imperative that the plan be reviewed every six months by the child's interdisciplinary team to ensure that the CAH I/II child is being cared for in the most effective manner.

The six-month review should include:

  • Confirmation of up-to-date level of care assessment;
  • A review of participant's needs to ensure they are being met by the current Service Plan;
  • Verification that Home Assessment Abstract is current and correct;
  • Verify that physician orders have been renewed as required every 60 days; and
  • Identification of current goals and an evaluation of those goals to determine if they remain appropriate.

The completion of a new plan of care every six months is no longer required.

4. Who may complete PPRI?

The Pediatric Patient Review Instrument (PPRI) must be completed by a Registered Nurse (RN).

5. Can any Registered Nurse (RN) complete the assessment?

The Uniform Assessment System (UAS-NY), (Pediatric 0-3 or the Pediatric 4-17) is used to evaluate LOC. The UAS-NY (Pediatric 0-3 or Pediatric 4-17) must be completed by an RN with online training (specific training modules) in the UAS-NY portal, available through Health Commerce System (HCS).

6. Will the CAH I/II Waiver cover bereavement services if the participant's death is sudden and unexpected?

CMS has reviewed and approved all services that are provided under the CAH I/II Waiver, and has stipulated that bereavement counseling services must be initiated and billed prior to the death of the child. A Physician's Order for bereavement services must be obtained prior to providing services, and will need to be renewed every sixty (60) days. In addition, bereavement services must be rendered by an approved Care at Home I/II palliative care provider.

7. What should we do if there are no local providers willing to provide bereavement services for pediatric cases?

To provide bereavement services under the CAH I/II Waiver, the counselor must possess one of the following qualifications:

  • Clinical Social Worker (LCSW) currently licensed in NYS pursuant to NYS Education Law, Article 154, Social Work, preferably having three (3) years clinical pediatric and one (1) year clinical end of life experience; or
  • Psychologist currently licensed in NYS pursuant to NYS Education Law, Article 153, Psychology, preferably having three (3) years clinical pediatric and one (1) year clinical end of life care experience; or
  • Mental Health Counselor currently licensed in NYS, pursuant to NYS Education Law, Article 163, Mental Health Practitioners, Section 8402, Mental Health Counseling, preferably having three (3) years clinical pediatric and one (1) year clinical end of life care experience.
  • Demonstrate ongoing proficiency in principles of end of life care through participation and successful completion of education and training, the curriculum must include instruction in communication with children and families, grief and bereavement process, and end of life care.

Any qualified provider meeting these qualifications should be encouraged to apply to become a CAH I/II Waiver provider. Hospice care provided through Medicaid State Plan services are also available.

8. The CAH I/II waiver application states that only one vehicle can be modified, but what if the child's parents have joint custody and separate vehicles?

CMS has reviewed and approved all services that are provided under the CAH I/II Waiver, and has stipulated that only one (1) vehicle may receive up to $25,000 of approved modifications over a five (5) year period. It will be up to the family to determine how to effectively manage this benefit, and to resolve issues that do not fall within the scope of the CAH I/II Waiver.

9. Will the Department of Health pay for an architect­ to complete Home Modifications?

Home Modifications have a cost limit of $25,000 per five (5) year period, and the Department of Health is not responsible for costs that exceed this amount. In addition, evaluation costs are included in the cost limit of $25,000. Providers performing any adaptation for a child in CAH I/II program is required to:

  • Be bonded;
  • Maintain adequate and appropriate licensure;
  • Must be able to clearly describe in writing, and by design, the proposed home adaptation and vehicle modification;
  • Obtain any and all permits required by the state and local municipality codes for modification; and
  • Agree that before final payment is made, the contractor must show that the local municipal branch of government that issued the initial permit has inspected the work.

The evaluator's fee should include the cost of any consultations, including the need and costs associated with the services of an architect.

10. Can air conditioning be covered under the Waiver benefits if it is necessary for respiratory or temperature control reasons?

The CMS Technical Guidance establishes that items of general utility are excluded (items which primarily benefit members of the household other than the child). These items include but are not limited to: central air conditioning, freestanding air conditioners, and humidifiers.

11. What should we do if counties require Protected Health Information (PHI) prior to conducting a visit?

As established in Appendix A of the approved 1915c waiver application, the Local Departments of Social Services (LDSS) are charged with implementing the Medicaid program including the CAH I/II program. Responsibilities of the LDSS include the authorization for participation in the waiver. Service providers should not withhold information from the LDSS as it will delay or prevent the participants entry or continued eligibility for waiver services.

12. What is meant by agencies providing case management services are not able to provide other services?

Published in the Federal Register on January 16, 2014 the Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act) establishes that person-centered service plan development cannot be performed by the individual's provider of direct services unless there is no other willing and qualified entity available to that individual.

These standards aim to ensure that case management is person-centered and promotes the person's interest; not that of the agency providing the services. NYSDOH has established that due to current provider qualifications and service structure, the CAH I/II waiver program is in compliance with conflict of interest standards

13. If case management agencies are unable to simultaneously provide case management and other services, how can a case manager be expected to provide crisis intervention?

Assistance and support with a crisis is considered to be within the scope of responsibility for case management and is not considered a discrete waiver service influenced by conflict of interest issues. CMS has defined Case Management Conflict of Interest (COI) as:

  • When the same entity helps an individual gain access to services and provides services to that individual;
  • When the same entity is responsible for assuring and honoring free choice of providers and is a service provider;
  • When the same entity is responsible for overseeing quality and outcomes on behalf of the individual and is a service provider; and
  • When the Case Management agency for an individual has a fiduciary relationship with a provider of services to that individual.

14. How does a waiver get submitted without a comment period?

Published in the Federal Register on January 16, 2014 the Medicaid Program; State Plan Home and Community-Based Services, 5-Year Period for Waivers, Provider Payment Reassignment, and Home and Community-Based Setting Requirements for Community First Choice (Section 1915(k) of the Act) and Home and Community-Based Services (HCBS) Waivers (Section 1915(c) of the Act) establishes the public comment period for 1915c waivers. The approved CAH I/II application was submitted to CMS prior to the enactment of this regulation, therefore a public comment period was not required.

15. When does the waiver authority end?

The current 1915c waiver application approved effective April 1, 2017 is approved for a five-year period. The application provides for the potential for the waiver to transition to managed care during that five-year period. CMS must approve the transition and closure of any 1915c waiver.

16. What is meant by "review?"

A review is a formal assessment or examination of something with the possibility or intention of instituting change if necessary.

17. What is meant by "screening?"

A screening is the evaluation or investigation of something as part of a methodical survey, to assess suitability for a particular role or purpose.

18. Will NYSDOH let us know when The Child and Adolescent Needs and Strengths (CANS) is approved for use?

The currently approved 1915c CAH I/II waiver application established the Uniform Assessment System (UAS-NY), (Pediatric 0-3 or the Pediatric 4-17) as the assessment to establish LOC. In order to change this requirement, NYSDOH must seek an amendment to the current application. Upon approval of the amendment, providers will be notified by NYSDOH.

19. Are the MCOs responsible for the Home Health Abstract?

Managed Care plans were advised of the following:

The Care at Home I/II Waiver Program is receiving inquiries advising the Department that Medicaid Managed Care plans are not completing the Home Assessment Abstract for eligibility or upon reassessment when completing the Pediatric UAS-NY. Please note: The Home Assessment Abstract is required to be completed for eligibility and at reassessment. The initial and ongoing Home Health Abstract and Pediatric UAS-NY are the responsibility of the managed care plan.

20. With the transition as of 1/1/18, how will children in the program continue if they already have primary insurance through their parents, and Medicaid as third-party?

Any questions regardingHealth Homes should be directed to the Division of Program Development and Management; Bureau of Policy and Programming. Health Homes' email address is HHSC@health.ny.gov.

21. Does NYSDOH still intend to release a HAA/3139 review form as previously indicated?

There will not be a specific HAA/3139 review form at this time. However, in the forthcoming manual and updated forms there is a six-month review form that addresses the review of the HAA.

22. Is it a violation of Conflict – Free Case Management if waiver services, such as environmental or vehicle modifications, are delegated to a case management agency?

A conflict would not exist because the Case Manager is not providing this service directly to an individual on their assigned caseload. CMS presents that a conflict of interest may exist when there is a fiduciary relationship that creates:

  • Incentives for either over- or under-utilization of services.
  • Possible pressure to steer the individual to their own organization.
  • Possible pressure to retain individual as a client rather than promoting choice, independence and requested or need service change.

23. Can you provide a regional list of trained providers, and how they will be paid?

There is no list of assessors available. There is a Communication Role Lookup Tool in the HCS to identify organizations (LHCSA and Home Health Agency) by region that have access to the UAS-NY. Currently, providers completing the Pediatric UAS-NY are reimbursed as a nursing visit.

24. What should we do if there has been a change in the child's health or circumstances after we have submitted documentation?

If any documentation or assessments are submitted and there is a significant change in the circumstances or care needs of the child applying for waiver services, those application documents must be updated. An applicant to the CAH I/II Waiver program may only be considered for enrollment if he or she meets the eligibility criteria for the waiver and upon submission of a complete and current waiver application packet to NYSDOH.

25.Doesn't the Waiver indicate that written reports are the responsibility of the local DSS or HRA, not the case management agency?

The waiver application does not specify what specific reports are required by a provider or authorizing entity. NYSDOH establishes these responsibilities through it operational manuals, ADMs and GIS notification system.