May 18, 2023 New Independent Assessments Procedure for NY Medicaid
New York Medicaid implemented major changes in its procedures for assessing the needs of applicants who are seeking community-based personal services or managed long-term care services. The changes became effective on December 1, 2022. If you or your family members are already receiving or preparing to apply for Medicaid coverage for community-based services, this blog post explains how the new “Independent Assessment” system affects your case.
Why Did Medicaid Change Community-Based Services Assessment Procedures?
The changes were required by terms included in the 2020 NY State budget, but the effective date for the change was delayed several times because of the COVID-19 public health emergency (PHE). Federal laws enacted in response to the pandemic prevented any reduction in services to Medicaid recipients. The new procedures were also delayed because time was needed to build the proper administrative infrastructure to execute the plan.
The old method of obtaining Medicaid approval for community-based personal assistance services to aid with activities of daily living (ADL) permitted an applicant to visit their doctor or other qualified healthcare provider. During the visit, their doctor could assess the patient’s need for services and then certify that they needed assistance carrying out one or more these basic living activities.
Following the doctor’s certification of the patient’s need for service in Form M-11Q, Medicaid would schedule an assessment by a nurse from a Conflict-Free Evaluation and Enrollment Center (CFEEC). These were nurses unaffiliated with any managed long-term care plan providers.
The New Assessment Process:
In the new system established for most new assessments of Medicaid applicants over age 18, the former conflict-free assessment will now be performed by the New York Independent Assessor (NYIA). Interestingly, the same state contractor (Maximus) that provided the conflict-free assessments is now performing all NYIA assessments.
In the new Independent Assessment procedure, your doctor is no longer a part of the process. Now, to enroll in a Managed Long Term Care Plan (MLTC) for in-home personal care services (PCS) or for client-directed personal assistance services (CDPAS), the application process begins by contacting the New York Independent Assessor (NYIA) directly.
When a person in need of community-based home care services or their representative contacts NYIA, the NYIA agent on the call will schedule two appointments:
- Appointment # 1 is with a nurse conducting a Community Health Assessment (CHA). This assessment uses the same criteria as was used in the old process to determine the following:
- That the applicant’s condition is stable. If the applicant’s condition is not stable, the services will probably not be approved.
- That the applicant needs assistance with at least 1 (one) activity of daily living (ADL). These activities are discussed below in the “What’s an ADL?” section. (In the future, applicants may be required to need help with three ADLs, or two ADLs, if the person has dementia. But this significant change in the criteria is not in effect now and is not likely to take effect until late in 2024 or 2025. Only after the state of New York spends all of the money it received from the federal American Rescue Plan (ARP), is it allowed to make changes in the eligibility criteria for community-based services.
- Appointment # 2 is with an Independent Practitioner Panel (IPP) which conducts
a) a clinical assessment (CA;) and,
b) produces a practitioner’s order (PO) which may confirm the applicant’s medical condition and certify that he/she meets the criteria to enroll in a managed long-term care plan or qualify for in-home personal care services or a client-directed personal assistant.
The Outcome Letter
Following the clinical assessment performed by either a physician, a nurse practitioner, or a physician’s assistant, the applicant receives a letter notifying them of the outcome of the assessments.
If the applicant is approved for enrollment in a managed long-term care plan, they may then contact an MLTC to determine how many hours they will be approved for. The plan’s representative will set up one more short assessment to determine which personal care services the individual needs and how many hours of care per week Medicaid should pay for.
What’s an ADL?
During the NYIA’s nurse assessment, the Community Health Assessment, the nurse is required to conduct an interview with the applicant or their representative about what help the applicant needs performing activities of daily living, or ADLs.
The ADLs that the nurse must focus on include the following: eating, walking, dressing, bathing, toileting, transferring, turning, and positioning.
Importantly, the NYIA nurse assessor is directed to limit their inquiry on assessment to how the applicant performed these ADLs only in the past 3 days. If the applicant for home-based personal services is deemed able to perform these tasks by themselves but with great difficulty, the nurse will find them to be independent and not in need of services.
In addition to the ADLs listed above, “cueing” is also considered an indication that the applicant needs in-home personal services. Cueing is reminding. For example, you might be able to take your own medication, but you forget to do so unless you are reminded. You may need to be reminded to toilet, or to shower. This is especially common with people suffering from dementia. People who need to be cued to perform these ADLs will be considered eligible for help.
Planning for the Assessment
Being properly prepared for your assessment is crucial. We assist our clients in best preparing for these NYIA assessments.
Who Does Not Need to Go Through NYIA?
Only new applicants for community-based personal care services or managed long-term care plans must proceed through the new department of New York Independent Assessment process. People who are already receiving these services do not need to go through NYIA. This is true even if they are transferring from one MLTC plan to another, or if they are seeking additional home care hours.
Immediate Need Applicants Do Not Need to Contact NYIA Directly
If someone has an immediate need for in-home personal care services, they or their representative can contact their local department of social services (LDSS) and proceed with an Immediate Need application. The LDSS is required to refer the applicant to NYIA, in which the assessments are completed over a shortened timeframe.
This could apply if a person is about to be discharged from an institutional healthcare setting and will need personal care services in their home immediately.
After 120 days of receiving immediate need services, the applicant receives a letter from New York Medicaid Choice to select and enroll in an MLTC plan. BEWARE of enrolling in a plan too soon, as you may lose your transition rights. Contact an Elder Law attorney before making changes that might cause you to lose your services.
There’s More To Know — Contact an experienced and skilled Elder Law and Medicaid Planning Attorney
This brief blog post can only report some of the overall changes that are part of the newly established New York Independent Assessor’s procedures. But there is much more to know.
If you or your family member are preparing to apply for New York Medicaid community-based services, you need to contact a knowledgeable professional to learn about how the program will impact your individual situation. Different requirements apply as a function of whether the applicant has both Medicare and Medicaid, or only Medicaid.
Elder law and special needs lawyers at Ely J. Rosenzveig & Associates have extensive experience helping individuals and families plan for and access Medicaid and social services. We’re here to help you and your loved ones get the help that you need.