Care at Home (CAH) I/II 1915(c) HCBS Waiver Program

Q: Will the UAS-NY also replace the DSS 3139-1 or just the PPRI in the community?

A: In order to be eligible for a 1915c waiver, all participants must require nursing facility/skilled facility level of care. The Pediatric Uniform Assessment System NY (UAS-NY) is the level of care assessment tool used by the Care at Home I/II (CAH I/II) waiver program to support that determination. Please note, however, the Pediatric Patient Review Instrument (PPRI) may be used to establish level of care on an interim basis. The UAS-NY must be completed within ninety (90) days thereafter.

Q: Will the UAS will replace Home Assessment Abstract (HAA)?

A: The UAS-NY and/or the PPRI do not replace the Home Assessment Abstract (HAA). The HAA is used to assess the child's home environment. The procedures for the use of the HAA have not changed. The assessment is included in the application for waiver services and must be updated every six (6) months while the participant continues to receive waiver services. Information garnered from the HAA assist in the development of the plan of care.

Q: What is the correct transition date to managed care: 1/1/18 or 7/1/18?

A: Upon approval by the Centers for Medicare and Medicaid Services (CMS), January 1, 2018 will set off a series of events to transition the 1915(c) Care at Home (CAH) I/II waiver into the 1115 authority using Health Home services. Children in receipt of 1915(c) waiver services will move from the fee for service Medicaid delivery system to the Medicaid managed care delivery system. Children otherwise exempt or excluded from Medicaid managed care enrollment will continue to receive these services through the fee for service delivery model.

Q: Will the State CAH I/II program have access to the UAS-NY?

A: The Local Departments of Social Services (LDSS) are responsible to assign all CAH I/II participants to their county caseload through the UAS-NY system. The County CAH I/II Coordinator also ensures that assessments are completed annually. Once the case is assigned (through the County's attestation), this allows access to the individual assessments. NYSDOH staff have access to the UAS-NY system. We are working to assign access to all approved waiver service providers.

Q: If a Case Manager (CM) cannot see the child face to face one month, does that mean we cannot bill for anything we do for the child in that month?

A: Case Management is a waiver service and is billed monthly. Case Management will not be reimbursed if the child is receiving a duplicative service such as Early Intervention Services or Medicaid Service Coordination. The waiver application states: "At a minimum, the case manager will maintain monthly face-to-face contact with the child. . .. there must be at least one face-to-face meeting provided each month… Face-to-face meetings should have a purpose and an outcome… At least one face-to-face meeting will occur in the child's home every six months." Failure to provide a monthly face-to-face contact indicates the provider is not in compliance with waiver standards.

Q: If Consumer Directed Assistance Services are considered to be Respite, then how is CDPAS budgeted?

A: CDPAS is not a Care at Home I/II waiver service. It is a state plan service. Respite is no longer included in the waiver application. Districts do not approve CDPAS on the basis of waiver eligibility and/or the Case Manager's recommendation, without conducting the necessary reviews and physician's orders required for state plan services. There is no monthly Medicaid budget cap for children enrolled in the CAH I/II waiver. However, there are service limits for specific services that may not be exceeded unless otherwise indicated in the participant's service plan and authorized by the LDSS.

Q: On the UAS-NY, what score qualifies a child to remain in CAH?

A: The Uniform Assessment System (UAS-NY) has been utilized as a principal clinical assessment tool across long term care populations in New York State since 2013. The assessment has three domains: functional health, condition and cognition status, with sub-categories such as activities of daily living, memory recall ability, neurological condition. Waiver eligibility requires a score of five (5) or greater.

Q: If a Case Management agency requests a copy of the UAS-NY, which was completed prior to waiver approval, may we give them a copy?

A: Review of the UAS-NY is necessary to establish and maintain waiver eligibility as well as support the plan of care and present long term care options. The assessment must be completed by a Registered Professional Nurse although other professionals may contribute to the assessment as appropriate. It is a web-based software application. Case Managers may have "read only" access to the system upon approval by NYSDOH. Copies of the assessment may be provided to Case Managers and parents upon request, in order to support the development of a plan of care.

Q: Where can I find the newly approved waiver?

A: The most recently approved waiver application is available on the Department of Health website under Long Term Care at: http://www.health.ny.gov/facilities/long_term_care/docs/2017-04-01_-_2017-12-31_care_at_home.pdf.

Q: Private Duty Nursing (PDN) is going to Mainstream Managed Care (MMC), can you elaborate?

A: Private duty nursing services are nursing services for Medicaid recipients who require more individual and continuous nursing care than is available from a Certified Home Health Agency (CHHA). Private Duty Nursing is a state plan service and not a Care at Home I/II waiver service. This question is more appropriately addressed with the managed care unit or private duty nursing unit.

Q: Who is responsible to complete the UAS within 90 days, the case management agency or LDSS?

A: The Local Department of Social Services (LDSS) CAH I/II Coordinator and Case Manager are responsible for arranging the assessment. Additionally, they are responsible for tracking the time frames for re-evaluation. An RN authorized to implement the UAS-NY completes the initial assessment, annually thereafter and whenever there is a change in the child's medical status. In accordance with program guidelines, the CAH I/II Case Managers are required to assist the participant/family in understanding, meeting, and completing necessary program requirements, such as the level of care assessments. Managed Care Plans will complete assessments for plan members and counties are responsible to maintain sufficient staff and/or providers by contract if necessary to complete assessments.

Q: Will the slides be available for the webinar? And will the webinar be recorded?

A: The June 15, 2017 slide presentation for CAH I/II stakeholders was provided to the LDSSs and will be posted on the Department website. This presentation was not recorded. The webinar presented subsequent to these FAQs will also be made available in the future.

Q: Can the UAS conducted for CDPAS be also used for CAH I/II waiver program?

A: The UAS-NY assessment is not specific to a service and is used to establish nursing facility level of care (NFLOC). As such, available assessments may be used to establish waiver eligibility. The UAS-NY must be dated within ninety (90) days of waiver eligibility and annually thereafter to maintain waiver eligibility.

Q: Please advise if there is a parameter for the 'annual' CAH level of care UAS-NY i.e. may annual be once per calendar year?

A: Re-evaluations of the level of care required for a waiver participant are conducted no less frequently than annually: every twelve months from the date of the last assessment. Enrolled waiver participants are re-evaluated in conjunction with the service plan review or at any time the participant experiences a significant change in condition. Initial assessments must be completed within ninety (90) days of waiver eligibility. Each CAH I/II Coordinator must maintain a file or log which indicates when each participant's level of care evaluation is due. Preferably, re-evaluations should be conducted in conjunction with the development and/or review of the plan of care.

Q: Please clarify review of the Home Assessment Abstract (HAA) and plan of care every six (6) months.

A: The Plan of Care and the Home Assessment Abstract (HAA) must be updated at a minimum, annually and reviewed every six months to clearly identify the current needs of the child. The plan must support that the participant's needs can be met through waiver and other medically necessary Medicaid state plan services. Physician's orders are renewed every sixty (60) days. New forms are being developed by NYSDOH to assist in this review process.

Q: Will the new service limits apply to Environmental Modifications (EMODS) currently in progress?

A: Upon CMS approval of the waiver application, there are a number of new service limits in place. In particular: the maximum expenditure for Home and Vehicle Modifications for the benefit of the individual Medicaid beneficiary may not exceed $25,000 for home and $25,000 for vehicle modification per five (5) year period. The time frame/amount is rolling based on the five (5) year period of the approved completed project and final completion costs.

Q: If CAH I/II services are discontinued as a result of hospitalization greater than 30 days, is there an edit/direction for case management services while the child is hospitalized? Also, if discontinued from CAH I/II waiver program due to hospitalization, can these cases be expedited once the child is discharged?

A: Federal regulations: 42CFR§441.301(b)(l)(ii) provides that waiver services may not be furnished to individuals who are in-patient at a hospital, nursing facility or ICF/MR. As such, if discharge is not anticipated within thirty (30) days, the child must be discontinued from the Care at Home I/II waiver program. Any provision of case management services would be considered a duplication of services and cannot be billed. Since there may be a change in the condition of the child as a result of the hospitalization or long term care, the process for reenrollment would remain the same as an initial application.

Q: Please confirm that the Home Assessment Abstract (HAA) may be "reviewed" at each reassessment, unless there is a change, such as a change of address. If there is a change in the home assessment, a new HAA would be completed by the nurse.

A: As stated previously, the Plan of Care and the Home Assessment Abstract (HAA) must be updated at a minimum, annually and reviewed every six (6) months to clearly identify the current needs of the child. The plan must support that the participant's needs can be met through the waiver and other medically necessary Medicaid state plan services. Physician's orders are renewed every sixty (60) days. New forms are being developed by NYSDOH to assist in this review process. If the home environment changes a new Home Assessment Abstract, would be required.

Q: If the CAH child has medical bills during the three (3) months prior to Medicaid eligibility, do we calculate the budget with the parental income for this time period to determine eligibility?

A: Medicaid eligibility questions should be directed to the LDSS. The CAH I/II waiver no longer imposes individual budget requirements. The waiver utilizes statewide aggregate data to support cost neutrality.

Q: Will the MLTC's contract with current CAH program Case Manager's to perform case management services? Or, will MLTC staff do the ongoing case management?

A: The CAH I/II population is not moving to Managed Long Term Care (MLTC). Health Home is a Care Management model for individuals enrolled in Medicaid with chronic conditions, including complex medical and/or behavioral health needs. Members that are eligible for and receive HCBS must also receive care management. Children that now receive 1915(c) services will transition to the 1115 HCBS authority. Children that become newly eligible for 1115 HCBS will receive the required care management through the Health Home infrastructure. Children otherwise exempt or excluded from Medicaid managed care enrollment will continue to receive these services through the fee for service delivery model.

The State has already begun work to facilitate Health Home affiliations with care managers that now provide 1915(c) care coordination/case management. Many of these case managers are affiliated with case management agencies that also provided case management under the Office of Mental Health Targeted Case Management programs that transitioned to Health Homes in the first part of 2017.

Beginning in early 2018, 1915(c) care coordinators that will transition to Health Home Care Managers will begin talking to their transitioning children and families about the Children's System Transformation, and supported by State guidance and training, will explain in general terms what it means to enroll in a Medicaid managed care plan (if the child is not already enrolled), what Health Home benefits are, how access to services and providers they work with today will continue without disruption, the expanded services that will become available in July 2018, why the State is transforming children's services, and when these changes will take place.

Q: We are still unclear as to whether the Home Assessment Abstract (HAA) must be completed for CAH I and II cases. We know the UAS-NY must be completed yearly, but are we still completing a HAA along with the budget and plan of care every 180 days.

A: The Home Assessment Abstract must be completed annually and reviewed every six (6) months.

Q: What will the LDSS CAH Coordinator role and function be after the transition occurs?

A: The State has developed a transition team that comprises the Department of Health, Office of Mental Health, Office of Children and Family Services, Office for People with Developmental Disabilities, and Office of Alcoholism and Substance Abuse Services. This transition team routinely solicits feedback from the Children's Health and Behavioral Health Subcommittees and external stakeholders. The transition team will continue to solicit feedback throughout the transition period. In addition, throughout the transition period, the State will hold webinars and in-person meetings to educate stakeholders regarding the processes to implement the provisions of the 1115 amendment. As the process moves forward, NYSDOH and the counties will define and document the scope and work expectations of stakeholders and providers.

Q: In the webinar you mentioned that a few services would no longer be available in the CAH waiver- one being CDPAS when used as respite service for parents. So is this in effect right now and if we have a client that is only getting CDPAS for this purpose are we to close them out? Does a new UAS have to be done with closing?

A: Respite services and Pain and Symptom Management were eliminated as waiver services, due to under-utilization and availability/duplication of state plan services. CDPAS is not a Care at Home I/II waiver service. The LDSS or Managed Care Plan approve CDPAS as a state plan service. Participation in services remain intact as approved in the participant's service plan. The participant will continue to receive CDPAS as long as the participant meets the service requirements.

Q: The State's Waiver Application omits children in foster care as a category of potentially eligible children, based upon its reference to parents and guardians only. Is this an intentional omission or an oversight?

A: The application does not omit foster care participants. CMS requested that the information be added by referencing the appropriate regulation(s). Please see Appendix B - Participant Access and Eligibility, Section B-4 Eligibility Groups Served in the Waiver. Other specified groups: 42 CFR 435.145 and 42 CFR 435.227.

Q: To date, CAH I/II children and their families have not received any written or verbal notification regarding changes to the CAH program. Foster children will be left ineligible for waiver services without notice. When and how will the State notify families of all proposed CAH changes?

A: NYSDOH has been working with the LDSSs to obtain the most recent and accurate participant enrollment information. Families will receive notification regarding waiver information via correspondence from the Department. Foster children remain eligible for waiver services.

Q: The Waiver Application describes several unfunded mandates for CAH Case Management Agencies, yet does not provide a mechanism for informing providers of the date a child will be determined CAH Waiver eligible nor a method by which agencies will be compensated for the work they do?

A: NYSDOH does not agree that there are unfunded mandates associated with waiver service provision. Many of the terms and conditions of the application are consistent with previous submissions. NYSDOH suggests that although not specifically identified, the rates include and accommodate broad functions completed by providers. Should the CAH I/II waiver not transition to managed care in 2018, providers will be required to complete cost reports, which will be effective in identifying supplemental costs incurred by providers. The date of waiver eligibility for CAH I/II waiver participants is provided to the LDSS upon approval of the application by NYSDOH.

Q: Given that MSC and EISC staff fall under TCM guidelines and as a function of their role are required to arrange for all transitions,why is this federal requirement being by-passed, resulting in the [unpaid] absorption of their responsibilities by CAH CM providers?

A: Federal requirements dictate that billing for Medicaid services cannot be duplicated.Therefore, billing for these services cannot overlap.

Q: Information regarding the use and frequency of the UAS-NY is inconsistent and conflictual in the documentation provided. Will the State please clarify its proposed process and frequency for CAH reassessments in the proper form of an ADM.

A: As stated previously, initial UAS-NY assessments must be completed within ninety (90) days of waiver eligibility and annually thereafter to maintain waiver eligibility. Re-evaluations of the level of care required for continued waiver participation are conducted no less frequently than annually: every twelve months from the date of the last assessment. Enrolled waiver participants are re-evaluated in conjunction with the service plan review or at any time the participant experiences a significant change in condition. Each CAH I/II Coordinator must maintain a file or log which indicates when each participant's level of care evaluation is due. Preferably, re-evaluations should be conducted in conjunction with the development and/or review of the plan of care. Due to the forthcoming transition to managed care, any future procedural guidance will most likely be conveyed via the Program Manual.

Q: Throughout the Waiver Application and the State's presentation, the following terms appear to be used interchangeably: plan of care, plan of services, service plan and case management plan of services form. Will the State please clarify whether all of these terms refer to the same document, and if so, utilize one term consistently to describe required documentation to avoid confusion at all levels

A: The service plan is part of the overall plan of care which includes: the Home Assessment Abstract, LOC assessment, physician's orders, service plan and budget. The case management plan of service has been eliminated and is now referred to as the service plan. Please note however, that many of these terms are used interchangeably. For example: in the application CMS refers to Participant Centered Planning and Service Delivery and Service Plan Development, just as Case Managers are often referred to as Service Coordinators and Care Managers. As we move to full implementation of the new application, CAH I/II Waiver forms will be appropriately identified. Please note that as the transition moves forward, terminology will change as plan of care is commonly used in the managed care environment and Case Managers are referred to as Care Managers.

Q: What is the legal basis for disallowing case managers to assist and support families in presenting their respective positions during the Fair Hearing process? In the absence of their respective CAH CMs to assist with representing their issues, many families will be completely unrepresented in the Fair Hearing process.

A: Please refer to the eMedNY LISTSERV notice dated August 14, 2013:

"While a service coordinator/case manager, other waiver providers or employing agency may discuss and provide additional information in response to a preliminary decision with which the agency disagrees, once a written determination to deny, discontinue, or reduce one or more waiver services has been made by the RRDC/LDSS or the Department, any advocacy or appearance on behalf of the participant by the waiver provider or parent agency to challenge such a decision is beyond the scope of the provider's functions set forth in the applicable Provider/Program Manuals/Administrative Directives. Such activity constitutes a conflict of interest for the service coordinator/case manager or other waiver provider and the employing in the agency's role as an agent of the Department for waiver purpose…but the practice of advocacy by a Medicaid provider who is in the position to receive financial gain by the advocacy is a conflict of interest or an appearance of a conflict of interest."

Q: The Waiver Application states that "CAH Case Managers are expected to meet face-to-face with all individuals on their caseloads as frequently as needed based upon each person's individual needs and circumstances," yet limits CM services to 10 hours per month unless "…authorized by the LDSS." Does the State have a defined process for ensuring that each child's need for CM services [beyond the allowable 10 hours per month] will be approved in an equitable and timely manner?

A: The service limits are established in the participant's service plan and reflect the total number of required hours of service annually. At the time the service plan is submitted to the LDSS for review and approval, the Case Manager should include an additional justification for the request for additional hours. This process will be more fully described in the Program Manual.

Q: Although we welcomed the opportunity to participate in last week's presentation we are greatly disappointed with the lack of ongoing communication, transparency and organization that the state has provided to agencies and the families they represent. We are also greatly concerned about the enormous confusion that lies ahead for children and families as they transition to managed Medicaid and a new model of care coordination. We strongly encourage the DOH topartner with provider agencies and engage them and families in program/service provision discussions.

A: Your concerns are duly noted.

Q: In order to effectively serve children throughout the State, CAH CMs often travel great distances to meet with their assigned children. A monthly site visit requirement coupled with a limit of 10 CM hours per month has the potential to severely limit an agency's ability to serve vast geographic areas and will likely impede a CM's ability to meet the basic needs of a child and family. How will these children remain in the CAH Waiver if agencies are unable to provide CM services?

A: The service definition included in the approved application provides the following language: "not to exceed 10 hours monthly, unless otherwise indicated in the participant's plan of care and authorized by the LDSS." The Case Manager should justify the need for the additional hours in the service plan and upon submission to the LDSS the approval will be considered. Should the request be denied, families will be afforded due process. Current review of provider billing suggests that the limit is sufficient to meet the needs of the majority of waiver participants. It should be noted that this service limit was dictated by CMS.

Q: Mainstream Managed Care (MMC) does not understand their role in obtaining assessments for CAH I/II.

A: We are assuming that the reference is to the implementation of the UAS-NY as that is the only new assessment implemented as related to the CAH I/II program. Please note that the UAS-NY is used for other state plan services and many of the CAH I/II waiver participants have existing assessments on file. In response to this concern, CAH I/II waiver staff met with the Division of Health Plan and Contracting Oversight and additional notification and clarification to the plans has been distributed.

Q: UAS- NY: Numerous CAH agencies utilize St Mary's CHHAto complete PPRIs for CAH I & II LOC's. We startedtraining our CHHA nurses severalyears ago on the UAS however up until now an implementation date was not provided so they continued with the PPRI. Our CHHA director reports itis very challenging to train staff on the UAS: time consuming and costly. From our understanding the UAS will only be utilized until the transition to health homes and the CANS. It seems a bit unreasonable to request staff be trained on an assessment tool only to abandon it in the near future. Thus the change to the UAS at this time seems to be a significant burden and an unfunded mandate.

A: The CAH I/II waiver application which was submitted to CMS in 2013 provided for the implementation of the UAS-NY which is used as the LOC assessment tool for other state plan and MLTC services. Providers were notified of the program's intent to implement the Pediatric UAS-NY at that time via an eMedNY LISTSERV notice. The decision to use the CANS was subsequent to the CAH I/II application submission. The Pediatric UAS-NY assessment training is provided in the UAS-NY system and requires approximately three hours to complete. All Registered Professional Nurses with UAS-NY access with the assigned role, may access the Pediatric tool upon completion of the training module. NYSDOH does not anticipate a large number of new CAH I/II applications requiring assessments. Re-assessments are completed annually and a PPRI may be completed until the UAS-NY is secured within ninety (90) days.

Q: Eligibility Date for Participation in the CAHI/II Waiver Program: "The 3-month retroactive period begins on the first day of the month the LDSS receives the complete, fully documented, signed and dated application. CAH I/II case management services will not be reimbursed if the child is receiving case management through Early Intervention." Most CAH referrals are 0-3 years old and meet EI eligibility requirements. Not being able to bill creates a costly unfunded mandate and potentially eliminates the ability to fund assessments completed by CHHA's. CAH I/II applications can be extremely complex and require a significant amount oftime. How could OPWDD CAH recognize the need to fund"transition services" (rate code 2326) that includes intake, screening activities, preparation of all enrollment documents and development of the initial plan of care and DOH CAH does not?

A: Please be advised that the rate structure established for the OPWDD waiver is completely different than CAH I/II as are the service definitions and the service limits. Due to the limited time frame leading to the transition to managed care, it is impossible to establish a new rate and rate code. Waiver services may not be provided and reimbursed if they are a duplication of services provided in the same time period.

Q: Can you confirm dates of new case management limits?

A: Effective October 1, 2017, caseload size limit of no more than 30 individuals per case manager, which is inclusive of any individual that the case manager renders case management services to. Effective April 1, 2017, case management services are limited to 120 hours annually, not to exceed 10 hours monthly, unless otherwise indicated in the participant's plan of care and authorized by the LDSS/HRA. As previously established, Case Managers are required to have monthly face-to-face contact with the participant and family.

Q: A child had a PPRI done 4 months ago, they are wondering if a UAS is required immediately or if it can wait until they do their next PPRI?

A: If the PPRI was completed prior to the approval of the waiver application, the UAS-NY will need to be completed for CAH waiver service eligibility at the child's next reassessment due date. If the PPRI was completed after the approval of the waiver application, a UAS-NY will need to completed within 90 days of the date of the PPRI.

Q: The Waiver Application does not describe the State's process for establishing a child's CAH enrollment effective date. In the absence of retroactive enrollment dates, required case management activities become significantly costly unfunded mandates, and in some cases, eliminates a means to fund initial CHHA assessment visits. What serves as the basis for the information referenced in a subsequent GIS?

A: The GIS establishes that the eligibility date for participation in waiver services may begin on the first day of the month, three months prior to the date that the LDSS/HRA receives a complete waiver application. The application must be complete, signed and dated.

Q: Currently some of the State's most experienced CAH CM providers are self-employed, with decades of advocacy experience and knowledge. In order to preserve this caliber of service provision, does the State intend to grandfather existing individual providers?

A: The decision to eliminate sole proprietors as waiver providers was not made by current waiver management staff. Review of current billing suggests the waiver population is being served by agency based providers. Although a sole proprietor may have been previously approved to provide services, it does not mean that they are actively engaged in service provision at this time. These providers should come forward and NYSDOH will make every attempt to accommodate their assigned caseloads. It should be noted that there are less than six months remaining until the transition to managed care begins. These providers are encouraged to transition into the Health Home system. The State has already begun work to facilitate Health Home affiliations with care managers that now provide 1915(c) care coordination/case management. However, sole proprietors will not be approved to assume any new cases at this time.