MLTC Policy 13.17 REVISED

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 13.17 REVISED: Care Management Protocol Guidelines - applicable to Partial MLTC and MAP plans

Date of Issuance: October 18, 2013


This document is intended to:

  1. Inform Managed Long Term Care (MLTC) plans of standards that must be reflected in each plan's Care Management protocols. These care management standards are applicable regardless of whether the plan provides care management services directly or contracts with another entity for care management services.
  2. Inform Managed Long Term Care (MLTC) plans of key areas that must be addressed in all Care Management Administrative Services (CMAS) contracts submitted to the New York State Department of Health (NYSDOH) for review. This is supplemental guidance to be used in conjunction with the Care Management Administrative Services Contract Guidelines ("CMAS Guidelines"), which have been revised accordingly and can be found at http://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm.

This document is intended to:

All MLTC Plans must ensure that their Care Management protocols meet the requirements detailed in items #1-9 below. If revisions are necessary to meet the new requirements, a redlined copy addressing any substantive changes must be submitted to the Department for review and approval. Plans who believe their existing protocols are in compliance with items #1-9 must submit an attestation indicating compliance. Plans are required to submit either revised protocols or attestation within sixty (60) calendar days from the issuance of this policy. Please note that plans who attest to compliance will be held to such statements, and could be subject to sanctions if the Department subsequently determines appropriate revisions were not made.

  1. Provide a minimum of one care management telephone contact per month for each enrollee;
  2. Provide a minimum of one care management home visit every six (6) months for each enrollee, which can be included as part of any re-assessment;
  3. Ensure that the level and degree of care management and the Plan of Care for each enrollee address the needs of the enrollee and are based upon the acuity and severity of enrollees' physical and mental conditions;
  4. Identify the ratio of care managers to enrollees taking into consideration a hierarchical structure based on the acuity and severity of enrollees' physical and mental conditions. If care management is provided in a "team approach," then the Care Management Protocols must address how the team operates;
  5. Identify methods to educate and inform the enrollee, as applicable, about Consumer Directed Personal Assistance Services (CDPAS) and other service options when creating the Plan of Care with the enrollee after the assessment and reassessments;
  6. Identify a reasonable minimum required response time to enrollee/member contacts. This should be based upon a hierarchy of need triage principle, that taking into consideration the enrollee's needs and types of request;
  7. Identify the qualifications needed of care managers to demonstrate that care managers have the appropriate background in health care, social work, nursing and/or long term care;
  8. The process for documentation in a record system of required phone contacts and home visits; and
  9. If Care Management responsibilities are delegated, the Care Management Protocols must provide that MCO shall timely notify the applicable Administrator of (i) new enrollees in the MCO, and (ii) enrollees that are disenrolled from the MCO. Such notice shall be consistent with when and how the MCO is notified by DOH and/or the enrollment broker of this information.

MLTC plans submitting Care Management Administrative Services (CMAS) Agreements:

All CMAS Agreements submitted to the NYSDOH must satisfy the requirements detailed in the CMAS Guidelines and items #1-9 listed above. The CMAS Agreement must contain a statement that the Administrator is required to comply with the Plan's care management protocols (policies and procedures).

Revised CMAS Guidelines are effective immediately upon release of this policy. Effective with this revision, templates are no longer permitted and will not be accepted for review. The Department recognizes care management as a core function of the Managed Long Term Care program and administrator-specific CMAS contracts provide the necessary level of detail required to accurately reflect each unique administrator-to-MLTC plan relationship.

New CMAS Contracts and material amendments to existing contracts for Care Management Services submitted to DOH for review on or after the release date must adhere to these new Guidelines. Contracts and/or material amendments to contracts that were submitted prior to issuance of these guidelines, must be amended to comply with these guidelines no later than December 31, 2013. CMAS Contracts should specifically address: (i.) which entity is responsible for completing assessments and reassessments; (ii.) which entity is providing 24/7 access to care management staff; (iii.) the requirements and process for Administrator to prepare and submit reports to the MCO; and (iv.) standards for adherence to MCO's Care Management Protocols, and MCO evaluation of Administrator performance.

  1. CMAS Agreements submitted subsequent to the release of this revised policy document must conform to these Guidelines and be submitted to DOH with a contract statement and certification form. These agreements remain subject to final DOH approval.
  2. Plans which believe their previously submitted CMAS agreements (templates or single source) are in compliance with these revised guidelines, must attest to that effect. Plans who attest to compliance will be subject to sanctions if the Department determines otherwise. Attestations must include the unique contract identifier(s) assigned to the CMAS agreement, as originally submitted to DOH. Plans which determine their CMAS agreements (template or single source) do not adhere to the revised guidelines must submit amendments in a red line version for Department review and approval.
  3. Subsequent changes to the Standard Clauses do not require the submission of contract amendments for DOH review and approval. The plan must substitute the updated Standard Clauses for the prior version in the agreement.

The MLTC plan will receive a written response (via e-mail) from NYSDOH staff indicating any issues or concerns. Once an agreement is acceptable, written approval will be issued.