MLTC Policy 15.06: Nursing Home Transition - Conflict-Free Evaluation and Enrollment Center UAS Requirements

Office of Health Insurance Programs

Division of Long Term Care

MLTC Policy 15.06: Nursing Home Transition - Conflict-Free Evaluation and Enrollment Center (CFEEC) and Uniform Assessment System (UAS) Requirements

Date of Issuance: November 24, 2015

The purpose of this policy is to provide clarification regarding CFEEC and UAS-NY assessment requirements for Medicaid recipients seeking Community Based Long Term Care Services (CBLTCS) and enrollment into a Managed Long Term Care Plan (MLTCP) upon discharge from a Nursing Home.

On February 1, 2015 the Department implemented a requirement for new permanently placed dual eligible nursing home (NH) residents to be mandatorily enrolled in a MLTCP that contracts with their NH. This requirement began on February 1, 2015 in New York City; extended to Nassau, Suffolk, and Westchester Counties on April 1, 2015; and transitioned to the remainder of the upstate regions effective July 1, 2015.

NH residents not enrolled in MLTCP

Those NH residents who are not enrolled in MLTC and who are approaching conclusion of a short term rehabilitative stay and seek to access CBLTCS upon discharge MUST be routed to CFEEC to establish eligibility for MLTC enrollment.

Any NH resident who was permanently placed prior to the effective dates of the NH transition and subsequently seeks return to the community with the support of CBLTCS and MLTC enrollment MUST be routed to CFEEC to establish eligibility for enrollment. Those individuals are not automatically deemed eligible for MLTCP enrollment.

MLTCPs must continue to comply with the UAS-NY assessment requirements that are in place for new enrollments. In accordance with MLTC Policy 13.09, MLTCPs are required to complete a UAS-NY Community Assessment within 30 days of referral and conduct a reassessment every 6 months or sooner if there is a significant change in condition. Each UAS-NY Community Assessment, as well as the Assessment Outcomes, conducted by the MLTCP, or its designee, must be fully completed, signed and finalized. Assessments that are not signed and finalized are not considered as evidence of compliance with the contractual requirement for the periodic comprehensive assessment.

The Community Assessment cannot be finalized if the information specific to the individuals home environment is not completed. It is understood that the MLTC is conducting the assessment in the nursing home; therefore, the MLTCP must make every effort to assess the persons home environment and address those required questions. If the nurse assessor must collect information from a collateral who is not available at the time of the assessment in order to complete the assessment, it is expected that the nurse gather the necessary information and sign and finalize the assessment and assessment outcomes within a day or two of the date that the assessment was conducted.

NH Residents who enroll in MLTCP

Effective October 1, 2015, permanently placed NH residents may voluntarily enroll in a MLTCP. Those permanently placed NH residents who enroll in a MLTCP may continue to progress and eventually consider returning to the community with the services of the plan. The MLTCP is NOT required to route that member to the CFEEC to establish eligibility. The MLTCP, member, NH, and physician will develop the person centered plan of care to effectively transition to the community with appropriate plan services and supports. MLTCPs are required to continue to comply with UAS-NY assessment cycle requirements for these members.

New community applicants versus those transitioning from fee for service

Individuals who are residing in the community and approach a MLTCP requesting enrollment MUST be referred to the CFEEC which will conduct an evaluation to determine eligibility. Dual eligibles in receipt of CBLTCS who have been notified by New York Medicaid Choice of the need to transition to a MLTCP are NOT required to have a CFEEC evaluation prior to enrollment in the plan. The MLTCP is required to conduct a UAS-NY Community Assessment within 30 days of the members enrollment in the plan.

MLTCPs should review its business operations and procedures to assure compliance with these protocols. It is important to recognize that each MLTCP is required to adhere to its contractual requirements and applicable laws, regulations, and policies. In addition, each MLTCP must ensure that its subcontractors, vendors, and per diem employees adhere to MLTCP contractual requirements and applicable laws, regulations, and policies.