CDPAP Services Covered by Mainstream Medicaid Managed Care as of Nov. 1, 2012 for People Without Medicare
02 Nov, 2012
On November 1, 2012, Consumer-Directed Personal Assistance Program (CDPAP) services were added to the benefit package for "mainstream" Medicaid managed care (MMC) plans. Most Medicaid recipients in New York State who do not also have Medicare, are already enrolled in these plans, or will be required to enroll soon, with only very limited exceptions or exclusions, described in this article. (See Map by County showing where MMC is mandatory). Also on November 1, 2012, CDPAP services must be covered by all Managed Long Term Care plans, which are now mandatory in New York City for dual eligibles (those who have Medicare and Medicaid) who need long-term community-based home care services.
The addition of CDPAP services to mainstream Medicaid managed care plans ("MMC") follows the addition in August 2011 of personal care (a/k/a home attendant services -- including housekeeping) services. In the past, people enrolled in mainstream MMC plans received most of their primary medical care through their managed care plan, but personal care/home attendant/CDPAP services were "carved out" of the managed care benefit package, so individuals applied for them through the local Medicaid offices (CASA offices in NYC). The home care providers billed Medicaid for the approved services on a fee-for-service basis, rather than under contract with the managed care plans. Now, the managed care plans will take over the role of assessing eligibility for and authorizing the number of hours of personal care and CDPAP services, and the plans will contract with and pay the personal care provider agencies and the CDPAP Fiscal Intermediaries out of their "capitation rate."
Note that this change only effects Medicaid beneficiaries for whom the following are true:
The August 2011 roll-out carving in personal care and housekeeping into the mainstream Medicaid Managed Care plans affected 5900 Medicaid recipients statewide, of which about 4100 are in New York City. The number affected by the Nov. 2012 addition of CDPAP services is not known.
On November 1, 2012 there should be no immediate change noticeable by CDPAP recipients who are in Mainstream Medicaid MMC plans. The MMC plans must contract with the existing CDPAP providers -- fiscal intermediaries -- in NYC and each county, as long as those fiscal intermediaries are willing to accept the current reimbursement rate paid by the county. The CDPAP fiscal intermediary is supposed to continue providing the same home care services that were authorized by the CASA/ DSS office. The only change is that the CDPAP provider agencies will have to bill the beneficiary's managed care plan for services provided after that date. The authorization period carries over, and the plans are required to continue paying the existing PCA provider to provide services for a 60-day transition period. Before the end of the 60 days, plans are expected to enter into contracts with PCA agencies, and this could cause some beneficiaries to have to switch agencies (and may lose their familiar aides, though the State has asked the plans to make an effort to keep continuity of aides). In addition, managed care plans may attempt to reduce hours on the next reauthorization; be on the alert for notices proposing changes to clients' care plans.
Some of the managed care plans have posted some information on their websites -- e.g.
What to do if a CDPAP aide does not report to work after November 1st, or if there are other coverage problems --
AFTER THE INITIAL TRANSITION PERIOD, the managed care plans will reassess client's hours -
We expect they will threaten to reduce hours. Clients should be receiving written notice of a proposed reduction -- but may not. Whether or not they receive a written notice, here's what you can do:
1. File a complaint and/or appeal with the Medicaid managed care plan.
2. File a complaint with the State Department of Health Managed Care Complaint Line at (800) 206-8125.
3. Request a Fair Hearing. During a fair hearing, an independent state administrative law judge will hear your case. If you requested a Fair Hearing because your services were reduced or stopped, you may also be able to continue to receive these services while your fair hearing is being decided. This is called “aid continuing.”