2016 LCM-02 - Immediate Need for Personal Care Services and Consumer Directed Personal Assistance Program (CDPAP)

To: Local District Commissioners

Subject: Immediate Need for Personal Care Services and Consumer Directed Personal Assistance Program (CDPAP)

Date: October 24, 2016

Division: Office of Health Insurance Programs

The purpose of this Local Commissioners Memorandum (LCM) is to provide local departments of social services (LDSS) with some additional clarification regarding 16ADM-02 which the Department issued on July 1, 2016. The purpose of the ADM was to outline the requirement to provide expedited determinations for Medicaid applicants and/or recipients who have an immediate need for Personal Care Services (PCS) or Consumer Directed Personal Assistance Services (CDPAS), based on regulatory amendments under 18 NYCRR Sections 505.14(b) and 505.28.

As these new requirements are being implemented at the local level, several questions regarding the various components of the regulations have been received. Many of those questions are answered below.

Q1: How soon does the assessment process need to begin? Is it following the receipt of the attestation or once the expedited Medicaid determination is made?

A1: The immediate need process is to occur concurrently, not consecutively, for the eligibility determination and the completion of the assessment.

Q2: Does the immediate need process begin when the attestation and related documents are received by the LDSS? Does this also include the Physician's orders?

A2: Yes, the 12-day immediate need process begins on the day that the documents are received from the LDSS eligibility staff. The Department strongly encourages that the Physician's Orders are sent in along with the related documents to ensure timeliness of determinations.

Q3: Can local districts authorize providers that have established Medicaid skilled nursing assessment rates to do PCA nursing assessments and bill eMedNY at those skilled nursing rates if there is no established PCA nursing assessment rate?

A3: Local districts may only contract with providers that have a valid Medicaid MMIS numbers on file with the Department. Additional questions about which rates may be utilized should be directed to the Department's fee-for-service rate setting unit.

Q4: What is the process for a provider to become established as a PCA provider in eMedNY and to secure a PCA nursing assessment rate? Also, please describe the anticipated timeline related to that process.

A4: To obtain a Medicaid MMIS number, providers must complete an application which is available on the eMedNY website. Approval takes an average of 90 days.

Q5: Local districts are bound by state model contract language, per the regulations, with all providers of Personal Care Services. Is there going to continue to be a requirement that we use the state model contract language or will that section of regulations be modified? If so, please provide that language.

A5: Revisions to the Personal Care regulations are currently under consideration. In the interim, current model contracts may be amended for the purposes of securing contracts to get assessments completed.

Q6: Will the Department require different contract language to be used when a provider with an approved PCS rate bills eMedNY directly versus when a Local District pays the provider directly and then claims for reimbursement? If so, please provide required language for both scenarios to Local Districts.

A6: Contracting protocols remain unchanged as well as the billing process when a Schedule E is used.

Q7: If a local district wants to contract with a private nurse or agency to do assessments and pay them on the Schedule E, what are the SDOH guidelines for rate setting by local districts? Are counties free to negotiate any rate and seek full reimbursement on the Schedule E claim? Are there any conditions required by SDOH for such an arrangement that could impact local districts receiving full reimbursement on the Schedule E claim?

A7: This is permitted as long as the current rate for a nursing visit is used.

Questions should be directed to your local district Medicaid liaison at:
For Upstate counties: (518) 474-8887
For NYC: (212) 417-4500

Sincerely, ___________________________________
Jason A. Helgerson
Medicaid Director