MLTC Policy 13.11

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.11: Social Day Care Services Question and Answers

Date of Issuance: May 8, 2013


The purpose of this release is to clarify the Department´s recent policy directives concerning Social Day Care services and Managed Long Term Care (MLTC), including issues addressed in the April 26, 2013 letter to MLTC plans from Jason Helgerson.

1. What is the Department´s expectation to complete activities referenced in the April 26, 2013 letter?

Effective with the April 26 release date, MLTCs should immediately engage in a review to address all issues articulated in the letter. MLTCs should change any current practices to ensure compliance with the Department´s directive.

2. Does a service change/reduction letter need to be sent to enrollees of MLTC plans if the plan is decreasing days of day care attendance?

Yes, any time services are decreased by an MLTC, a notice must be sent to the enrollee.

3. Do the personal care service hours have to be more than the social day hours attended?

An enrollee who receives personal care hours qualifies for MLTC as they are in receipt of Community Based Long Term Care (CBLTC) services. However functional needs identified in the assessment, along with identified goals and benefits of the service, should be clearly tied to authorization of the Social Day Care service. Plan service authorization criteria for Social Day Care services should capture these decision points.

Plans should review their Social Day Care service authorization criteria and all applicable marketing material to ensure these concepts are appropriately reflected, if any material changes to existing processes are required the revision must be submitted to the Department for approval.

4. Since this is not really a scheduled reassessment SAAM or significant change in condition, what type of SAAM assessment would be appropriate?

The SAAM should be reviewed by the nurse assessor for continued accuracy. If the review reveals a discrepancy between the SAAM functional assessment and the plan of care, a significant change reassessment should be conducted. The plan of care should be revised accordingly.

5. If a member wants to disenroll to attend social day care only, will Medicaid fee-for-service pay for this service?

Social Day Care service is not a Medicaid fee-for-service option. An individual may choose to attend a local Senior Center or pay privately for Social Day Care services.

6. How does the MLTC plan determine the role of informal supports in a plan of care when evaluating need for CBLTC and Social Day Care services?

Informal supports can be an integral part of an enrollee´s plan of care. However, informal supports cannot replace personal care services for the purpose of determining eligibility for CBLTC services.

7. If a person has no need for, or refuses, in-home CBLTC services can the person remain in the MLTC plan if the only service authorized is Social Day Care services?

The need for CBLTCS must be documented during the initial assessment process, clearly identified in the plan of care, and considered on an ongoing basis during reassessments. Social Day Care services can contribute to the total care plan but cannot represent the primary service provided to the enrollee. Enrollees must continue to need CBLTCS to remain enrolled in a plan.

If upon reassessment an enrollee no longer needs or refuses CBLTCS, disenrollment should be initiated. Continued stay in a MLTC plan may not be justified solely upon receipt of Social Day Care services. Upon this identification these enrollees may choose to voluntarily disenroll from the MLTC plan. Otherwise, an involuntary disenrollment must be pursued following the current process with New York Medicaid Choice/Local Department of Social Services as appropriate.

8. Are MLTC´s required to monitor Social Day Care service provision?

Plans are required to have a formal process for credentialing providers on a periodic basis (initially and not less than once every three years) and for monitoring provider performance. Plans should enter into contracts only with providers which have demonstrated capacity to perform the needed contracted services.

9. Can MLTCs care management staff visit an enrollee at a Social Day Care site?

MLTC plans may allow their care management staff to visit an enrollee at the contracted Social Day Care site, with the understanding that such visit is conducted with appropriate privacy protection.

10. What actions does the Department contemplate to enforce the new social day care services guidance?

The Department will be working with the Office of the Medicaid Inspector General which will conduct audit activities on all enrollments in accordance with developed audit protocols. The Department will recoup any capitation payments made to the plan for any non-eligible enrollees. The Department will consider prohibition of marketing and enrollments activities for any plans that are determined to be non- compliant with the Department´s recent guidance.

11. How does a plan determine what entity is an appropriate source of Social Day Care services?

In accordance with the existing contract between the Department and all Managed Long Term Care Plans (MLTC), plans are required to have a formal process for credentialing providers on a periodic basis (initially and not less than once every three years) and for monitoring provider performance.

Plans should enter into contracts only with providers which have demonstrated capacity to perform the needed contracted services.

Although there is not a specific license or certification, in order to be assured of enrollee health and safety, all providers of Social Day Care services must meet the standards and requirements of 9 NYCRR 6654.20.

In order to ensure the health and safety of members, MLTC plans may choose to conduct site visits of Social Day Care (SDC) services prior to entering into a contract and on a periodic basis thereafter to monitor performance.