Person Centered Service Planning Dear MLTC Health Plan Administrator letter

  • Letter also available in Portable Document Format (PDF)

January 22, 2019

Dear Health Plan Administrator:

This communication is intended to highlight and reinforce Managed Long Term Care Plans' ("MLTCPs" or "Plans") adherence to their obligations relating to enrollee assessments, informal supports, and the development of the Person-Centered Service Plan ("PCSP" or "plan of care") and when the PCSP must be provided to the enrollee.

PCSPs should be based on the initial assessment and reassessments of the enrollee. The Plan must address all the enrollee's assessed scheduled and unscheduled needs and/or personal goals. It must include services delivered in home and community-based settings. The Plan must use a person-centered process that identifies strengths, capacities and preferences of the enrollee, as well as identifying the enrollee's long-term care needs and the resources available to meet those needs. The Plan must first determine whether the enrollee, because of the enrollee's medical condition, would be otherwise eligible for PCS or COPAS, including continuous or live-in 24-hour services. If the enrollee has any unscheduled needs which will not be met by PCS or COPAS, the Plan must identify how such needs will be met by documenting the other services to be used to meet them, such as informal supports and adaptive or specialized equipment and supplies. Ultimately, the schedule of home care aide hours and the mix of other services and supports documented in the PCSP must adequately meet the enrollee's scheduled and unscheduled needs.

A PCSP must include covered services and ensure their coordination with non-covered services and services provided by other providers, community resources or informal supports. The PCSP should document the types, scope, amount, and frequency of services the enrollee will receive. This will include, but is not limited to, PCA, HHA, DME, Ancillary, informal supports, Back-up plan, identified unscheduled needs, and other covered/non-covered benefits. The Plan must provide a copy of the PCSP to the enrollee after each assessment. A new PCSP must a!so be provided to the enrollee if changes are made to the PCSP for any reason, such as change in condition or reassessment.

When an enrollee uses informal supports, the PCSP must include the name, address, and phone number of the enrollee's informal supports and the name and phone number of the enrollee's care manager. The PCSP must also document the day(s) and time(s) that formal supports and voluntary care from informal supports are expected to be provided, taking into account any l<nown variability in the day(s) and time(s) of services provided by formal or informal supports, as well as the type and scope of services they will provide. Informal supports include voluntary assistance available from informal caregivers including, but not limited to, the enrollee's family, friends, or other responsible adults. Formal supports include PCS, nursing services, HHA, COPAS, and adult day health care services. If the Plan is notified that an informal support will not be able to assist the enrollee at the scheduled time(s), the Plan must use reasonable efforts, to cover those hours and/or tasks taking into account the amount of notice and the availability of additional service providers. Plans are not required to update the PCSP to document temporary changes in the enrollee's schedule, or other scheduling changes unrelated to the type, amount, or scope of services between assessments.

If revisions are required to capture this information on the current PCSP, the Plan must submit the PCSP for DOH approval no later than sixty days from receipt of this communication.

Very Truly Yours:

Erin Kate Calicchia
Deputy Director, Division of Long Term Care Office of Health Insurance Programs