Some things that anyone who uses home care should know

What is CDPAS and why is it valuable to people with disabilities?

A great many New York State citizens with disabilities who have mobility or functional (e.g., limb use) limitations have been able to live independently in their own homes, rather than institutions, thanks to Consumer-Directed Personal Assistance Services (CDPAS). While they may require a Personal Assistant (PA) for such things as cooking, bathing, dressing, personal hygiene, light housekeeping, etc., if they are doing the hiring, scheduling, evaluation, and termination of their PAs, and otherwise making their own decisions, they are in control of their own lives. But finding PAs that will perform this sometimes literal "heavy lifting" on a regular basis for modest wages is always a challenge.  

Under CDPAS, Medicaid employs Managed Care Organizations (MCOs) to determine appropriate services for each consumer, while a Fiscal Intermediary (FI) organization (usually a Center for Independent Living) handles vetting of PAs, payroll, paperwork and other Medicaid-mandated requirements.

But there are issues with CDPAS

New York State has made some changes in policy, recently, that affect this beneficial program. We understand that, at the same time consumers' PAs are facing a loss of wages and the ability to work overtime, calling into question their ability to continue the already difficult task of recruiting and retaining staff, they are also facing large cuts in hours. The majority of complaints have been from the MCOs Nascentia Health, Inc. and Fidelis Care. Changes made by the New York State Department of Health (DOH) in the 2019-20 budget to "streamline and create efficiencies in the fair hearing process," also serve to make it more complicated for consumers to challenge reductions in hours, so we anticipate more reductions in hours.

Appeals of coverage cuts are possible, but the process is complex

We at WNYIL wish to inform our consumers of their rights under the Medicaid program. The New York Legal Assistance Group (NYLAG), Empire Justice Center, and New York Legal Aid, among others, have been working to inform Medicaid recipients of the changes. Evelyn Frank of the NYLAG Legal Resources Program coherently explained these rights by distilling the complicated process into a two-page reference sheet which is duplicated, below.

You can get detailed information from Western New York Law Center's "NY HEALTH ACCESS" article on Grievances and Appeals at this URL: http://www.wnylc.com/health/entry/184/

Important Change for Medicaid Managed Care and MLTC Enrollees
Appeals and Fair Hearing Rights

1. What is changing on May 1, 2018?

New rules change how and when you can ask the State for a Fair Hearing to appeal a decision by your Medicaid managed care plan, HARP plan, or Managed Long Term Care (MLTC) plan. Starting May 1, 2018, if your plan denies, reduces or stops a service, and you think the decision is wrong, you must first ask your plan to look at your case again. This is called a Plan Appeal. You must then wait for the plan’s decision before asking for a Fair Hearing.

This is a big change. Before May 1, 2018, you could request a Fair Hearing right away if you thought your plan’s decision about your services was wrong. Now you must first request a Plan Appeal before you can ask for a Fair Hearing.

2. What happens if the plan decides to reduce or stop a service I am getting now?

The plan must send you a written notice called an “Initial Adverse Determination” at least 10 days before the date the plan says that it will reduce or stop any of your services. You have 60 days from the date of the plan’s notice to ask for a Plan Appeal, but if you want to keep your services the same while your case is appealed, you must ask for a Plan Appeal within 10 days of the date of the plan’s notice or by the date the notice says the change will take effect, whichever is later. If you request the Plan Appeal within 60 days but after the effective date of the reduction, you can ask the plan to “fast track” your Plan Appeal. If you lose your Plan Appeal, you may ask for a Fair Hearing. If you don’t request a Fair Hearing, or if you don’t win your Fair Hearing, and you received your services unchanged while waiting for the decision, you may have to pay for those services.

3. What happens if the plan denies my request to approve a new service or more services?

For some services, you have to ask the plan for approval before you get them. If the plan denies approval, it has 14 days to send you a notice of its decision. If your health is at risk, you or your provider may request that approval be “fast tracked.” This requires the plan to decide in 72 hours. The decision may take up to 14 days longer if the plan needs more information. The plan must send you a notice explaining why it needs more information, and why the delay needed to obtain this information is in your interest. If your plan covers prescription drugs, the plan must make decisions about your prescriptions in 24 hours.

If the plan denies your request for approval, the decision is called an “Initial Adverse Determination.” If you think your plan’s decision is wrong, you can ask for a Plan Appeal. After May 1, 2018, you must first ask for a Plan Appeal and wait for a plan appeal decision before you may ask for a Fair Hearing. You have 60 days to ask for a Plan Appeal. If you disagree with the Plan Appeal decision, you may ask for a Fair Hearing.

4. How do I request a Plan Appeal?

You can request a Plan Appeal by completing and faxing or mailing the Appeal Request Form that came with the plan’s Initial Adverse Determination Notice. Some plans allow you to e-mail the request. The plan’s contact information for requesting the appeal should be printed on the Appeal Request Form. You can also call the plan to request the appeal, but you will then also need to mail or fax confirmation of the request, unless you ask your Plan Appeal to be “fast tracked.”

5. Can someone ask for a Plan Appeal for me?

If you want someone, like your medical provider, a family member, or a representative to ask for the
Plan Appeal for you, you and that person must both sign and date the appeal request. Or you must
give written permission to that person to request an appeal for you, unless you gave them permission in
the past.

6. What happens in a Plan Appeal and How Long Does it Take?

After you ask for a Plan Appeal, the plan will send you and your representative your case file, with all
the information they have about your request. You may submit new evidence for the plan to consider in
its review. The plan will send you its decision about your appeal within 30 days. If your health is at risk
and you or your provider request a “fast track” appeal, your plan must decide it within 72 hours. The
decision may take up to 14 days longer if the plan needs more information. The plan must send you a
notice explaining why it needs more information to decide, and why the delay needed to obtain this
information is in your interest. If the plan’s appeal decision denies you all or some of the services you
are seeking, the plan must send you a “Final Adverse Determination.”

7. What if the Plan does not decide my Plan Appeal on time?

If you do not receive a “Final Adverse Determination” – a decision for your Plan Appeal -- by the time
limits in the question above, you can ask for a Fair Hearing without waiting for the plan’s decision.

8. What if I think the Plan Appeal decision is wrong?

If you think the plan’s decision about your appeal is wrong, you can ask for Fair Hearing. You will have
120 days to ask for a Fair Hearing, but if the plan is reducing or stopping a service you are getting right
now, and you want your services to stay the same and not be reduced during the appeal, you must
ask for a Fair Hearing within 10 calendar days from the date of the appeal decision or by the date
the appeal decision takes effect, whichever is later. Your services will stay the same as they were
before, until the fair hearing decision. If you lose your Fair Hearing you may have to pay for services
you got while waiting for the decision.

If the plan said the service is not medically necessary, you can ask the State for an External Appeal.
You will have four months to ask for an External Appeal. Your services may be reduced while awaiting
an External Appeal, unless you also requested a Fair Hearing in time to prevent a reduction.

You can ask for a Fair Hearing or an External Appeal or both. If you ask for both, the Fair Hearing
decision will always be the final answer.

9. Where can I get more information?

For advice or assistance with a plan appeal or fair hearing with an MLTC plan, a HARP plan, or for
Long Term Services and Supports such as home care with a Mainstream Medicaid Managed Care
Plan, call ICAN – Independent Consumer Advocacy Network Phone: 844-614-8800

TTY Relay Service: 711

Website: icannys.org

Email: ican@cssny.org

Call NYLAG – EFLRP contact eflrp@nylag.org 212-613-7310

See http://www.wnylc.com/health/entry/184/ for more information.