HLT-35-13-00003-P Adult Day Health Care Programs and Managed Long Term Care
8/28/13 N.Y. St. Reg. HLT-35-13-00003-P
NEW YORK STATE REGISTER
VOLUME XXXV, ISSUE 35
August 28, 2013
RULE MAKING ACTIVITIES
DEPARTMENT OF HEALTH
PROPOSED RULE MAKING
NO HEARING(S) SCHEDULED
I.D No. HLT-35-13-00003-P
Adult Day Health Care Programs and Managed Long Term Care
PURSUANT TO THE PROVISIONS OF THE State Administrative Procedure Act, NOTICE is hereby given of the following proposed rule:
Proposed Action:
Amendment of Part 425 of Title 10 NYCRR.
Statutory authority:
Public Health Law, sections 201(1)(v) and 2803(2); and Social Services Law, section 363-a(2)
Subject:
Adult Day Health Care Programs and Managed Long Term Care.
Purpose:
To create a hybrid model of adult day health care.
Substance of proposed rule (Full text is posted at the following State website:www.health.ny.gov):
The proposed amendments make a number of changes to 10 NYCRR Part 425, governing the operation and payment of adult day health care (ADHC) programs in residential health care facilities. The purpose of the amendments is to enable such programs to contract and work effectively with managed long term care (MLTC) plans and coordinated care models (CCMs) as more Medicaid recipients are required to enroll in MLTC plans and CCMs. The proposed amendments also allow residential health care facilities to offer a hybrid program, in which individuals requiring ADHC services and individuals requiring only social adult day care services can both receive services in the adult day health care program space.
Section 425.1
Amendments are made to the definitions of “Registrant”, “Operating hours for an adult day health care program”, and “Visit”, and new definitions of “Care coordination model”, “Comprehensive assessment”, “Care plan”, “Hybrid option”, and “Social adult day level individual” are added.
Section 425.3
Amended to allow operators of approved ADHC programs to elect the hybrid option.
As part of their responsibility to manage and coordinate the health care needs of their enrollees, MLTC plans and CCMs provide certain services that ADHC programs are also required to provide for their registrants. Amendments are made to these regulatory sections to avoid duplication of services with respect to ADHC registrants who are referred to the ADHC program by an MLTC plan or CCM. In addition, section 425.6 is amended to provide for increasing the approved capacity of an ADHC program that elects the hybrid model.
Section 425.23
A new section 425.23 is added, with respect to payments to ADHC programs, to allow a MLTC plan or CCM to order less than the full range of adult day health care services for a particular enrollee, based on an enrollee’s individual medical needs as determined in the comprehensive assessment performed by the MLTC plan or CCM, and to enter into reimbursement arrangements with the ADHC program operator that take into account a registrant’s receipt of less than the full range of adult day health care services.
Text of proposed rule and any required statements and analyses may be obtained from:
Katherine Ceroalo, DOH, Bureau of House Counsel, Reg. Affairs Unit, Room 2438, ESP Tower Building, Albany, NY 12237, (518) 473-7488, email: regsqna@health.state.ny.us
Data, views or arguments may be submitted to:
Same as above.
Public comment will be received until:
45 days after publication of this notice.
This rule was not under consideration at the time this agency submitted its Regulatory Agenda for publication in the Register.
Regulatory Impact Statement
Statutory Authority:
Section 2803(2)(a)(v) of the Public Health Law authorizes the Public Health and Health Planning Council to adopt and amend rules and regulations, subject to the approval of the Commissioner, that define standards and procedures relating to medical facilities, including nursing homes. Section 201(1)(v) of the Public Health Law and section 363-a of the Social Services Law provide that the Department is the single state agency responsible for supervising the administration of the State’s medical assistance (“Medicaid”) program and for adopting such regulations, not inconsistent with law, as may be necessary to implement the State’s Medicaid program.
Legislative Objective:
Chapter 59 of the Laws of 2011 enacted a number of provisions of the Medicaid Redesign Team (MRT). One of these provisions calls for the mandatory enrollment of additional categories of Medicaid recipients into managed long term care (MLTC) plans or other care coordination models (CCMs). The proposed regulations would amend a number of provisions in 10 NYCRR Part 425, governing the operation and payment of adult day health care (ADHC) programs in residential health care facilities, to remove regulatory obstacles to those programs transitioning from being primarily fee-for-service Medicaid providers to being providers that can contract and work effectively with MLTC plans and CCMs.
Needs and Benefits:
The proposed amendments provide that the MLTC plan or CCM that refers an enrollee to an ADHC program will be responsible for meeting certain Part 425 requirements that are currently the responsibility of the ADHC program operator, consistent with the MLTC plan’s or CCM’s responsibility to manage and coordinate the enrollee’s health care needs. This will avoid having the ADHC program operator duplicate services that are required to be provided by MLTC plans and CCMs to their enrollees.
The proposed amendments clarify that the full range of ADHC services are available to MLTC plan and CCM enrollees with a medical need for such services. This ensures that Medicaid-covered ADHC services provided through an MLTC plan or CCM remain equal in amount, duration, and scope to ADHC services available to recipients of fee-for-service Medicaid.
However, the proposed regulations also allow an MLTC plan or CCM, based on an enrollee’s individual medical needs, as determined in the comprehensive assessment performed by the MLTC plan or CCM, to order less than the full range of adult day health care services, and to enter into reimbursement arrangements with the ADHC program operator that take into account a program registrant’s receipt of less than the full range of adult day health care services. The proposed rule allows MLTC plans and CCMs to order, and ADHC programs to provide, only the needed individualized services identified in the registrant’s comprehensive assessment and care plan, at a negotiated price that both the MLTC plan/CCM and the ADHC program can afford.
Finally, the proposed amendments allow residential health care facilities to offer a hybrid model, in which individuals requiring ADHC services and individuals requiring only social adult day care services can both receive services in the adult day health care program space. Social adult day care services are appropriate for individuals who do not need skilled nursing and medical services, but who are functionally impaired and will benefit from the receipt of services such as socialization, supervision and monitoring, personal care, and nutrition. This will have the effect of increasing the capacity of social adult day care programs, which is currently insufficient to meet the anticipated demands of MLTC plans in certain parts of the state.
Costs to the Department, the State, and Local Government:
The proposed rule will not increase costs to the State or local governments.
Local Government Mandates:
This proposed rule will not impose any program, service, duty, additional cost or responsibility on any county, city, town, village school district, fire district or other special district.
Paperwork:
This proposed rule will not impose any additional paperwork for ADHC programs.
Duplication:
There are no duplicative or conflicting rules identified.
Alternative:
No alternatives were proposed to the Department or considered.
Federal Standards:
The proposed regulations do not exceed any minimum federal standards.
Compliance Schedule:
ADHC programs should be able to comply with the proposed regulations when they become effective.
Regulatory Flexibility Analysis
Effect of Rule:
The proposed rule can potentially affect 165 adult day health care (ADHC) programs across the state. It will not affect any local government entities. The proposed rule allows an ADHC program approved to operate by the State of New York to elect the hybrid option, thus permitting the program to admit and serve social adult day level and ADHC level individuals during the same period of time, in the same physical space. It also allows these programs flexibility in their operations and permits them to more effectively contract with managed long term care (MLTC) plans. Since selecting this hybrid option is voluntary on the part of any ADHC program, it is impossible to know how many of the 165 programs will be affected. They may exercise this option as MLTC is expanded across the state and their decision to do so will be based on individual program experience, the location of the program and other community-based services available in their geographic area.
Compliance Requirements:
In order to exercise the hybrid option, the ADHC program will have to notify the Department in writing, thirty days in advance of implementation that they plan to exercise this option. ADHC programs are currently required by regulation to meet certain reporting and recordkeeping requirements, and these activities will not be increased for a program that elects the hybrid option.
Professional Services:
ADHC programs currently employ, either directly or through a contract, nurses; social workers; physical, occupational and speech therapists; certified nursing assistants; activities and dietary staff. These same types of individuals will continue to be employed since any ADHC program must have a full range of services available based on the needs of the population they serve. However, programs will be able to adjust their staffing based on the mix of social level and ADHC level registrants they serve on any given day.
Compliance Costs:
There are no direct or increased compliance costs as a result of this proposed rule.
Economic and Technological Feasibility:
This proposed rule will not change how ADHC providers serve or bill for registrants for whom they receive a fee-for-service Medicaid payment. Therefore, it will not have an impact on the program’s technological needs for these registrants. The number of individuals for whom a fee-for-service payment is received is likely to decrease as individuals are enrolled in MLTC plans, and thus the number of direct billings attributable to ADHC to the State will also decrease. The decrease in the number of fee-for-service registrants will have a negative economic impact on ADHC providers. This proposal will permit ADHC programs to address this by allowing them to offer social level adult day services and more effectively contract with MLTC plans. ADHC providers may have to improve their technology in order to bill and effectively communicate with the MLTC plans that they contract with, but these changes are not the result of this proposal. Any need to increase their technology, in this instance, is the result of the changes in the long term care market in general and the expansion of MLTC plans.
Minimizing Adverse Impact:
There will be no adverse impact on local government. The proposed rule is designed to allow ADHC program operations to be more flexible. Further, it will allow ADHC programs and the registrants they serve to more effectively adjust to the statutory mandate requiring the expansion of MLTC.
Small Business and Local Government Participation:
The proposal reflects the Department’s collaboration with the Adult Day Health Care Council, which is a trade association representing more than 90 percent of the ADHC programs operating in New York State. Members of the Council helped develop the concept of a hybrid option and had the opportunity to contribute to and comment on the concepts presented in this proposed rule.
Rural Area Flexibility Analysis
Types and Estimated Numbers of Rural Areas:
All rural areas of the state in which adult day health care (ADHC) programs are located will be equally affected by this proposal. There are approximately 41 programs operating in rural counties.
Reporting, Recordkeeping and Other Compliance Requirements; Professional Services:
For ADHC programs, no new reporting, recordkeeping or other compliance requirements are being imposed as a result of this rule. The only new requirement, should an ADHC program opt to utilize the hybrid option, will be to notify the Department of that decision in writing.
Costs:
No direct costs will be imposed as a result of this rule.
Minimizing Adverse Impact:
There will be no adverse impact on rural areas. Implementation of this rule will benefit managed long term care plans expanding to rural areas that will need to include medical and social model programs in the benefit package. The rule will allow programs to increase capacity with social level registrants and serve a larger population. Implementation of the rule may prevent program closures and displacement of registrants to nursing facilities. The rule will allow for continuity of care as registrants will receive different levels of treatment in one setting.
Rural Area Participation:
The Department participated in multiple meetings with the Adult Day Health Care Council which represents more than 90 percent of the ADHC programs in the state, including the 41 programs operating in rural areas.
Job Impact Statement
Nature of Impact:
The statutory mandate requiring the expansion of Managed Long Term Care (MLTC) will likely have a negative impact on adult day health care (ADHC) programs. As MLTC expands, enrollment in ADHC programs as currently structured may significantly decrease. This could result in the downsizing of programs and staff, closures and displacement of the registrants. The proposed rule was designed to mitigate such an impact by providing ADHC programs flexibility in their operations and permitting them to more effectively contract with MLTC plans. The proposed rule, therefore, could prevent job loss that might otherwise occur if it is not adopted.
Categories and Numbers Affected:
The staff affected by the proposal include: nurses; certified nursing assistants; physical, occupational and speech therapists; social workers; dietary/food service workers; housekeeping and activity professionals.
Regions of Adverse Impact:
Adoption of the proposed rule will not result in an adverse impact on jobs or employment. The proposed rule permits ADHC programs to select a hybrid option through which they deliver their services. Selection of this option is voluntary, and will be based on individual program experience and choice. Therefore, it is impossible to know how many programs or which regions of the state would be affected.
Minimizing Adverse Impact:
One of the reasons the Department wishes to adopt this proposed rule is to minimize any adverse impact on ADHC registrants and programs which may result from the mandatory expansion of MLTC plans.
