New Assessment Process

Summary

NOTE: This is a proposed regulation change and a developing policy area. As more details are learned, we will update this page.

A diagram of the CDPAP assessment process as of July 20202. Step 1. Independent Assessor or IA conducts CHA Assessment. Step 2. IA orders independent physical for CDPAP. Step 3. Managed Long Term Care company (MLTC) or Local Office of Social Services develops Plan of care. IA refers case to independent review panel if consumer requires 12 or more hours per day average. IA conducts annual reassessments or change in condition assessment.

ALL CURRENT CDPAP Consumers must go through the new assessment process. The tentative start date is 1/2/21 and includes the following elements:

Independent Assessment (IA)
Independent Physician
Development of plan of care (including cost-effectiveness of services)
For consumers with an average of 12+ hours of care per day, an additional assessment is required

Independent Assessment

From January 2, 2020 to October 1, 2022, the Conflict Free Conflict Free Evaluation and Enrollment Center (CFEEC) aka Maximus will serve as the Independent Assessor (IA). Maximus will also be responsible for obtaining physician orders for services. In October 2022, the Department will transition the activities to a separate entity.

No later than 10/1/22, the DOH will use either an independent assessor or multiple assessors to conduct assessments and reassessments to determine an individual's need for Personal Care Services, including CDPAP.

No later than 4/1/21, the department of health will create and implement an "evidence based" uniform task-based assessment tool to determine the amount of Personal Care Services and CDPAP hours of care per day. This tool will be used to "assist" managed care plans and local departments of social services determine the number of hours.

The IA will be responsible for

Community Health Assessments (CHA) and Reassessments
Physician’s Orders for Personal Care Services (PCS) and Consumer Directed Personal Assistance Program (CDPAP)
Panel Review of 12+ Hours Per Day Case

The assessment will include:

An assessment of the functions and tasks required by the consumer
A discussion with the consumer or designated representative to determine their perception of his / her circumstances and preferences
Assessment of potential informal supports (i.e. family members, friends, etc) which must take into account the following
Number and kind of informal supports
Ability and motivation of informal supports
How involved the informal supports will be
Future availability of informal supports
If the consumer is willing to accept care from these informal supports

Managed care plans will retain the responsibility to develop the plan of care and conduct care management and utilization review. Plans may also conduct other assessments (i.e. falls risk). In addition, plans may seek DOH approval of alternative care management models.

All determinations must not exceed seven (7) business days after independent assessment and physician order, or the clinical review panel recommendation if applicable, except as provided under the immediate need process.

Independent Physician Orders

The medical professionals who perform the exam and sign the physician order must be employed by or contracted with an entity designated by the Department of Health.

The independent physician:

Must be independent, meaning that they must not have a prior established provider-patient relationship with the individual.
Must review the independent assessment
May review of other medical records and consult with consumer's physician and others involved with patient's care
Must determine if the consumer is self-directing
Must determine if the individual can be safely cared for at home

Managed Care / County Develops Plan of Care

Counties or managed care plans will retain the responsibility to develop the plan of care and conduct care management and utilization review.

The county or managed care plan:

Must review the independent assessment and independent physician order
May again directly evaluate consumer to determine:
If services are medically necessary
If services can maintain the consumer's health and safety in the home in accordance with DOH regulations
If the consumer is able and willing to fullfil their responsibilities in CDPAP

If the individual receives services solely for monitoring a medical condition and well-being, can the consumer be monitored appropriately and more cost-effectively by a Personal Emergency Response Service.

If the individual can be served appropriately and more cost-effectively by other long term care services and supports including, but not limited to the assisted living program or the enriched housing program

If the individual can be served appropriately and more cost-effectively with adult day care or social adult day care

The MLTC / county must first consider the use of these services first over personal care services "to achieve the maximum reduction in his or her need for home health services or other long-term care services"

Sleeping arrangements for live-in 24 hour cases

The MLTC / county must first evaluate sleeping arrangements for the Personal Assistant

When the consumer’s home has no sleeping accommodations for a consumer directed personal assistant, continuous consumer directed personal assistance must be authorized for the consumer

If circumstances change and sleeping arrangements become available, a new review must take place

Additional Review for High-Hour Cases

The budget contains language that grants the DOH the power to adopt standards and assessment methods to verify if an individual's need for Personal Care Services exceeds a specified level and

"... is capable of safely remaining in the community in accordance with the standards set forth in Olmstead v. LC by Zimring, 527 US 581 (1999) and consider whether an individual is capable of safely remaining in the community."

A panel of physicians will review cases where consumers require an average 12+ hours of care per day. The panel will review the medically necessity / clinical rationale and recommend if the plan of care is able to keep the member "safely" at home.

Elements of the Review Include:

Required when an average of 12 hours of care is needed per day
Will be performed by an independent panel of medical professionals and coordinated by a lead physician
The lead physician cannot be the physician who was involved in the initial examination or physician order
The independent medical review will recommend if the plan of care is reasonable and appropriate to maintain the individual’s health and safety in his or her home and identify any other Medicaid services that may be appropriate, and include the clinical rational for such recommendation
The recommendation may not include specific hours of services or an alternative plan of care.
The LDSS or MMCO, as applicable, must consider the recommendation of the review panel in its decision to authorize services.

Frequency of Reauthorization (Physician Orders)

The reauthorization of consumer directed personal assistance shall only require a new physician order annually unless a new physician order is clinically indicated by the independent assessor.

Resources

Budget References

Full Budget Bill (New Assessment Tool - page 273, Independent Assessment - page 264, Independent Physician - page 264, Frequency of Physician Order Changes - page 273)
FY2020 Budget Scorecard (summary)
Proposed Regulation Changes (July 15, 2020)
Proposed Changes in the State Register (July 15, 2020)
DOH Presentation on New Assessment Process (June 2020)

Additional Resources

NYLAG Analysis of Budget Changes
The National Law Review Summary of Budget Changes (July 16, 2020)
LeadingAge New York Summary of Changes (July 28, 2020)