NEW YORK INDEPENDENT ASSESSOR PROGRAM  (NYIAP) - How Medicaid Home Care Eligibility is Assessed

IN THIS ARTICLE:

Two Official Websites about NYIA

  1. Maximus website   https://nyia.com/en  (also in Espanol) (launched June 2022)
  1. STATE DOH website on Independent Assessor with government directives here - https://www.health.ny.gov/health_care/medicaid/redesign/nyiap/ 

https://www.health.ny.gov/health_care/medicaid/redesign/nyiap/2023-10-03_rollout.htm 

WHEN DOES NYIA START?   NYS DOH has delayed NYIA  phase-in as follows   - and more detail here

CONTACTS - How to Request NYIAP, Where to  REPORT PROBLEMS, Request Evidence Packet, Submit a Power of Attorney - and OTHER KEY NUMBERS 

Form to Designate a Representative - REVISED - now separate from the Information-Sharing  Consent Form

What is the NY Independent Assessor Program? The Basics 

These are the basic steps used for these 3 populations - (for more info see Feb. 8, 2023 webinar recording here and NYLAG's slide deck from the webinar) 

  1. anyone seeking to enroll in an MLTC plan (started May 16, 2022),

  2. for a mainstream managed care member to request NEW personal care or  CDPAP services (started May 16, 2022 for standard time requests and Dec. 1, 2022 for expedited requests) or

  3. for those exempt or excluded from MLTC or mainstream managed care to request NEW personal care or CDPAP services from the local Dept. of Social Services (LDSS)(started May 16, 2022 for standard applications and Dec. 1, 2022 for "Immediate Need requests."

Consumer/rep calls NYIA at 1-855-222-8350 to schedule TWO assessments:  -- Consumers can appoint a representative to talk to NYIA on their behalf. See form and fax number to submit it here.   

  1. Independent Assessment (IA)  by a Nurse from NY Medicaid Choice -- this is the same Uniform Assessment that NY Medicaid Choice has long done for the Conflict Free Eligibility and Enrolllment Center.  Now, this will be the sole nurse assessment.  The plans and Local DSS must use this assessment instead of doing their own.  This assessment will first determine if the individual meets the new minimum-ADL requirement, if this is a new application.  
    • "(iii) The independent assessment must assess the consumer where the consumer is located including the consumer’s home, a nursing facility, rehabilitation facility or hospital, provided that the consumer’s home or residence shall be evaluated as well if necessary to support the proposed plan of care and authorization or to ensure a safe discharge. This provision shall not be construed to prevent or limit the use of telehealth in the assessment of a consumer.."   18 NYCRR 505.14(b)(2)(I)(c);  505.28(d)(1)(iii) 

  2. Independent Practioner Panel (IPP) or C.A. - exam by PHYSICIAN, physician’s assisant or nurse practitioner  from NY Medicaid Choice, who prepares a Physician's Order (P.O.)   In MLTC, this is NEW.  Doctor’s orders (M11q) had not been required.

    • Note: the IPP/CA may wish to clarify information about the consumer’s medical condition by consulting with the consumer’s provider’s.  The consumer must give provider’s permission to do this.  NYIA has its own form for this purpose.  See NYLAG fact sheet explaining how to complete and submit this form.

    • TREATING PHYSICIAN’S ROLE IN PRESCRIBING PERSONAL CARE OR CDPAP IS REPLACED by this Independent Practitioner panel. 

      Personal care and CDPAP services must be prescribed by a qualified independent physician selected or approved by DOH. The law authorizes using Maximus (NY Medicaid Choice) instead of procuring a new contractor.

      Side note: Aside from the lack of familiarity a contract physician would have with the consumer’s condition, compared to a long-time trusted physician, and the lack of specialization in the consumer’s particular diagnosis, this requirement adds even more delays to applying for services.  

After the 2nd Notice, NYIA sends an Outcome Notice  --

3rd Assessment must be scheduled if either an MLTC plan, a mainstream managed care plan or the LDSS determine that the indivdiual needs more than 12 hours/day on average, then they must refer it back to NY Medicaid Choice for  a third assessment - the Independent Review Panel in next section below. (Section 11).

  1. INDEPENDENT REVIEW PANEL (IRP) - The 2020 MRT II law authorizes DOH to adopt standards, by emergency regulation, for extra review of individuals “whose need for such services exceeds a specified level to be determined by DOH."  DOH's regulations draw this line at those needing more than  12 hours/day of home care on average. The assessor will review whether the consumer, “with the provision of such services is capable of safely remaining in the community in accordance with the standards set forth in Olmstead v. LC by Zimring, 527 US 581 (1999) and consider whether an individual is capable of safely remaining in the community.” (Sec. 2, 20).  Again, this is a panel run by New York Medicaid Choice. 

Side note: While we are pleased to see the seminal U.S. Supreme Court Olmstead decision cited specifically in the law, the entire notion of vetting a high-hour case to consider whether the individual is “capable of safely remaining in the community” raises huge Olmstead concerns. Even now, before these changes are implemented, those who need high hours such as 24-hour care must fight decisions by MLTC plans that they must be permanently placed in a nursing home.

Who is the arbiter of “safety?” What about the consumer’s autonomy – their right to the “dignity of risk” in choosing to accept some risks that may exist in the community in order to live at home as they choose? And their right to the medically necessary supports to meet their daily needs? Invoking concerns about “safety” is an old pretext for denying services–a pretext that the Americans with Disabilities Act (ADA) was enacted to combat.

WHERE ARE THE POLICIES AND PROCEDURES FOR THE INDEPENDENT ASSESSOR-  State and HRA?  

NYLAG Slide decks and webinars on NYIA - 

STATE REGULATIONS  & POLICIES ON INDEPENDENT ASSESSOR AND NYLAG COMMENTS 

Final state regulations  on Personal Care and Consumer-Directed Personal Assistanc (CDPAP) were  posted on the NYS DOH website on August 31, 2021, published in the NYS Register on Sept. 8, 2021.  Direct link to regulation is here.   The regulations have an effective date of Nov. 8, 2021, but they will not all be implemented on that date.   NYLAG was disappointed that the final regulations were virtually same as the  proposed state regulations to which NYLAG and other organizations submitted comments in March 2021.  Most of our recommendations were rejected.   

On Dec. 13, 2021, DOH posted an ADM and MLTC policy on some minor changes in the state regulations, but not on the major new Independent Asssessor procedures.   See 21 ADM-04 & MLTC Policy 21.06 - announce changes including:

On Nov 8, 2021, State DOH  posted a webinar clarifying which of the recent personal care and CDPAP regulation changes will go into effect on Nov. 8, 2021. (Recording) - (Web) - (PDF) (11.8.21). 

  1. WHAT IS DELAYED:  The new minimum of 3 ADLs (2 if have dementia)  for home care and MLTC, and the new Independent Assessor procedures,werel NOT implemented yet, but later the Independente Assessor  

  2. WHAT STARTS NOVEMBER 8, 2021 -  The regulation  cuts back on consumer rights after a "Transition Period."  These changes will make it easier for a plan to reduce hours after a consumer is required to transition to a new MLTC plan.  This could be after their old plan closes, or after they received Immediate Need services for 120 days, or after they first became enrolled in Medicare and had previously received home care from a "mainstream" Medicaid managed care plan.  Read more about these transition rights and how they are changing along with advocacy tips, here.

NYLAG COMMENTS Submitted on State Regulations & Policies  to Implement the Changes -


Article ID: 253
Last updated: 27 Feb, 2025
Revision: 1
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