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ADMINISTRATIVE DIRECTIVE
Transmittal:
2018-ADM-06R2
To:
Executive Directors of Voluntary Provider Agencies
Developmental Disabilities Regional Offices and State Operations Offices Care
Managers and Care Coordination Organizations (CCO) CEOs
Issuing
OPWDD Office:
Office of Strategic Initiatives (OSI)
Division of Policy and Program Development (DPPD)
Division of Service Access, Program Implementation and Stakeholder
Support
Date:
Revised August 2022
Subject:
Transition to People First Care Coordination
Suggested
Distribution:
OPWDD Providers
Contact:
OSI/DPPD
[email protected]
Attachments:
Attachment A
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PURPOSE:
Effective July 1, 2018, OPWDD issued Administrative Memorandum #2018-06, entitled
“Transition to People First Care,” to update existing regulations, policies, administrative
memoranda (ADMs) and Memoranda of Understanding (MOUs) as the Office for People
With Developmental Disabilities (OPWDD) transitions its care management service to
the Care Coordination service. Effective May 5
th
2019, OPWDD issued ADM #2018-
06R to replace ADM #2018-06 to make certain clarifying revisions retroactive to July 1,
2018. This ADM, ADM #2018-06R2, replaces ADM #2018-06R and is effective August
19
th
, 2022. New revisions are underlined and in red.
DISCUSSION:
A. Transition to Health Home Care Management and Basic Home and
Community-Based Services (HCBS) Plan Support Services
There will be a one-and-a-half-year transition period from July 1, 2018, through
December 31, 2019 (“transition period”). During this transition period, both
Individualized Service Plans (ISPs) and/or Life Plans may be in effect throughout the
OPWDD service system.
Effective July 1, 2018, the person coordinating an individual’s services and supports
and developing their Life Plan will be called a Care Manager. All references to a
Medicaid Service Coordinator “MSC” in existing policy, regulation, or ADM are replaced
by/intended to mean Care Manager. The term “Life Plan” replaces any references to an
ISP in any ADM, policy, or regulation, except with respect to specific billing
Related
ADMs/INFs
2018-09R,
2017-03, 2017-02,
2017-01, 2016-03,
2016-01, 2015-07,
2015-06, 2015-05,
2015-04, 2015-02,
2015-01, 2014-04,
2014-02, 2014-01,
2013-03, 2012-04,
2012-02, 2012-01,
2011-01, 2010-02,
2009-03, 2006-04,
2006-01, and
2002-01
Releases
Cancelled
2018-06R
Regulatory
Authority
14 NYCRR
633.12
MHL & Other
Statutory Authority
MHL §§ 13.01,
13.07
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requirements for ISP documentation for any claims for services provided during the time
period an ISP was in effect.
B. Life Plans & Staff Action Plans
1. Creating a Life Plan
CCOs are responsible for creating, updating, and maintaining Life Plans. An
individual’s ISP, created prior to July 1, 2018, will remain in effect until a Life
Plan is developed and finalized. An individual’s ISP must be converted into a
Life Plan by a Care Manager pursuant to the requirements in the Care
Coordination Organization/Health Home (CCO/HH) Provider Policy Guidance
and Manual, available at:
https://opwdd.ny.gov/system/files/documents/2020/01/cco-policy-manual-
master_acc_1.pdf No later than December 31, 2019 all ISPs, including
those for Tier 4 individuals, must be transitioned to finalized Life Plans.
After an individual’s ISP is replaced with a Life Plan,
ISP documentation is not acceptable to support service claims. Instead,
service claims must be supported by a copy of the individual’s Life Plan for
the time period of the claim.
As of July 1, 2018, individuals new to the OPWDD system (i.e., on or after
July 1, 2018), will have Life Plans developed and finalized in accordance with
the CCO/HH Manual. Finalized Life Plans for newly enrolled CCO members
(i.e., members enrolled after 10/1/2018) are due no later than 90 days after
CCO enrollment or HCBS waiver enrollment, whichever comes first.
Additional information available at:
CCO/HH Provider Policy Guidance and Manual Updates
Once an individual’s Life Plan has been developed and finalized per the
CCO/HH Manual, the Life Plan becomes the active plan of care document.
2. Finalizing a Life Plan
A Life Plan is finalized when it is signed by the Care Manager and the
individual receiving services or their representative. The other parties
identified in section 2c (below) must also sign the Life Plan.
a. The individual or representative’s signature
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documents their written informed
consent. This written informed consent can take the form of a physical
signature which can also be a scanned signature; a digital signature, an e-
signature.
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If the individual is incapable of signing the Life Plan, the following
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The individual’s representative can sign the Life Plan on their behalf if the individual is unable to provide written
informed consent.
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An electronic signature is an electronic sound, symbol or process attached to or logically associated with an
electronic record and adopted by a person as their signature. ESRA and its implementing regulation further define what
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options are available for documenting their informed consent:
1. The individual’s representative may sign on their behalf.
2. A mark made by the individual on the Life Plan that can also be
scanned indicating their informed consent or other mechanism that
clearly demonstrates the written informed consent of the individual and
its connection to the specific Life Plan.
3. A stamped signature if the individual is unable to sign because of a
physical disability.
4. Additionally, CCOs may choose to invest in technology capable of using
technology that has a verbal signature capability.
b. If the representative is not capable of Signing the Life Plan because of their
non-availability (e.g., the representative is on an extended stay in another
state) or the representative has requested an alternate method of documenting
their approval, then the following options are allowable as a last resort:
1. An email from the individual or representative that directly connects the
applicable Life Plan with the written informed consent.
2. A signed letter from the representative that indicates their written informed
consent.
Attachment A to this document is an e-mail template that may be used by the
representative to document their approval of the Life Plan. The attestation
language used in Attachment A must be included in either of the last-resort
signature options (i.e., e-mail or signed letter).
CCOs must include the allowable methods for obtaining the individual’s and
representative’s written informed consent in its policies and procedures which
must be made available to individuals, service providers and others as
applicable. The written informed consent/signature of the individual or their
representative, if applicable, must be retained and distributed as required with
the electronic Life Plan and made available upon review by DOH, OPWDD
and external audit entities.
c. At a minimum, providers
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responsible for delivering services
documented in Sections II and/or III of the Life Plan must sign the Life
will constitute an electronic signature in New York State. Guidance on electronic signatures in NYS can be found here:
https://its.ny.gov/electronic-signatures_and-records-act-esra https://its.ny.gov/sites/default/files/documents/nys-g04-
001_electronic_signatures_and_records_act_ersa_guidelines.pdf
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The term ‘provider’ or ‘service provider’, for the remainder of this document, shall refer to those agencies providing
day habilitation, residential habilitation, community habilitation, prevocational services, pathway to employment and/or
supported employment and any other provider or individual that is assigned a goal, supports and safeguards in
Sections II and/or III of the Life Plan. If the individual self-directs their services, and a self-directed staff person is
assigned a goal, support, or safeguard in Sections II and/or III of the Life Plan then a representative of the Fiscal
Intermediary must sign the Life Plan. The individual’s Support Broker may serve as the Fiscal Intermediary’s
representative for this purpose. A Respite provider may not have an assigned goal, support or safeguard and
therefore would not be required to sign the Life Plan, but in these cases the Care Manager must, at a minimum ensure
that the Respite provider is sent a copy of the finalized Life Plan.
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Plan to acknowledge and agree to provide the provider-assigned goals,
supports, and safeguards associated with those services, per the
finalized plan. The service provider’s signature indicating
acknowledgement and agreement may be done via signature or in the
following manner when the signature on the Life Plan itself cannot be
obtained:
1. A Staff Action Plan signed by the service provider that aligns with the
provider assigned goals, supports, and safeguards in Sections II
and/or III of the Life Plan can suffice to indicate service provider
signature of the Life Plan.
2. A signed letter or other attestation from the provider that indicates their
written informed consent.
The service provider’s signature on the Life Plan and/or Staff Action Plan
indicating acknowledgement and agreement to provide the goals,
supports and safeguards associated with their services should be done
after the Life Plan is finalized.
Service providers are responsible for reviewing the finalized, acknowledged
and agreed to Life Plan. Providers may occasionally find inaccuracies in the
finalized, acknowledged and agreed to Life Plan. Providers should
demonstrate due diligence in working with the Care Manager, CCOs,
OPWDD and/or others to correct the Life Plan as soon as possible. Service
providers should document their timely efforts to correct any errors in the Life
Plan. Examples of this documentation may include notes in the individual’s
monthly summary, e-mails, phone calls, etc.
When an individual’s ISP transitions to a finalized Life Plan, their goals/valued
outcomes and safeguards will be integrated into the Life Plan. Habilitation
Plans are not attached to the Life Plan, as the goals/valued outcomes and
safeguard needs components are in the Life Plan itself.
Section IV [four] of the Life Plan is required to identify all HCBS and State
Plan services that have been authorized for the individual.
3. New Services Prior to Life Plan Finalization
When HCBS waiver services are needed prior to the finalization of a Life
Plan, there must be sufficient documentation to support service authorization
for provider service billing. Sufficient documentation prior to Life Plan
finalization includes: (1) the OPWDD Developmental Disabilities Regional
Office (DDRO) approved Request for Service Authorization (RSA); and (2)
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the acceptable supporting information justifying the need for services as
outlined in the January 7, 2019 Memorandum titled Care Coordination
Organizations Policy Update: Service Authorizations Post July 1, 2018.
4. Life Plan Section IV: Specification of Duration, Effective Date, and
Frequency for HCBS Waiver Services
A Life Plan identifies an effective date (i.e., beginning date). It does not
need an end date as it remains in effect until a new Life Plan is finalized.
For the initial Life Plan, the effective date for each HCBS waiver service
is the same as the effective date of the initial Life Plan and is identified in
the effective date field of Section IV [four]. The Life Plan, and the services
described in the Life Plan, remains in effect until a new Life Plan is
finalized. If a new Life Plan is not finalized in the expected timeframe, the
services do not expire (i.e., the service remains authorized by the DDRO
for the individual). A failure to finalize or review a Life Plan within the
required timeframes may result in billing disallowances in a fiscal audit.
For individuals who currently have ISPs and are transitioning to the Life Plan,
the effective dates of the HCBS Waiver services should be listed as the first
effective date of the Life Plan (i.e., the “from” date which is the date of the Life
Plan meeting), not the date previously outlined in the individual’s ISP. For
example, if an individual’s ISP lists Community Habilitation as an HCBS
Waiver service with an effective date of 9/13/17 and the individual’s Life Plan
meeting is on 2/15/19, then the effective date for Community Habilitation in
the Life Plan should read 2/15/19.
When services are newly added to the individual’s Life Plan after the initial
Life Plan is finalized, the effective date of each new service should
correspond to the Life Plan review date on which the new service was added
to the Life Plan. For example, The Life Plan was finalized on 2/1/19. The
individual requests a new service, and a Life Plan review meeting is held on
5/15/19 to discuss this request. Day Habilitation is added to the individual’s
Life Plan during the Life Plan review meeting. The effective date for Day
Habilitation is 5/15/19.
The duration of the HCBS Waiver service is identified in the Life Plan in
Section IV [four] in either the effective date column or comments column (and
either “ongoing” or “ongoing as authorized” is acceptable where applicable).
The frequency of the HCBS Waiver service is identified in the Life Plan
through the unit column in Section IV [four]. Information on the required billing
documentation standards, including frequency and duration of HCBS waiver
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services, for Section IV [four] of the Life Plan can be found in the ADM for
that specific service (i.e., Supported Employment, Community Habilitation,
etc.).
Additionally, New York State regulations require each Medicaid provider to
prepare records to demonstrate the provider’s right to receive Medicaid
payment for a service. These records must be prepared
“contemporaneously.” 18 NYCRR 504.3(a).
5. Staff Action Plans
Under an ISP, individuals’ goals were carried out via a Habilitation Plan,
which was created by the Habilitation provider. Under a Life Plan, the
identified goals/valued outcomes are identified within the individual’s Life Plan
and are carried out via a Staff Action Plan created by the Habilitation provider.
Staff Action Plan requirements are contained in ADM #2018-09R (available
at: ADM #2018-09R Staff Action Plan Program and Billing Requirements.).
Effective July 1, 2018, the term “Staff Action Plan” is implied to replace any
reference to a Habilitation Plan in any existing policy, regulation, or ADM,
except with respect to specific billing requirements for Habilitation Plan
documentation for any service claims for services provided during the time-
period a Habilitation Plan was in effect.
6. Dispute Resolution During The Life Planning Process
All parties are encouraged to work collaboratively and well in advance of the
required time-period for Life Plan finalization. If the individual, service
provider(s), and/or the individual’s care planning team disagree about the
details of the Life Plan, the Care Manager must work throughout the life
planning process to facilitate resolution by implementing the dispute
resolution process developed by the CCO, as required in the CCO/HH
Manual, as well as the person-centered planning process. Care Managers
should employ their training and use of their own clinical resources to
facilitate consensus and appropriate resolution of any disagreements
between the parties. As needed, the Care Manager may also reach out to
the OPWDD Regional Office for technical assistance.
In the unlikely event that the dispute resolution process has been exhausted
by the Care Manager and a resolution still has not been reached regarding
elements of a Life Plan within the required time-period for finalization, the
following should occur:
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i. At the Life Plan Meeting(s):
a. If the disputed element represents a change to a previously
approved service, support or goal in a prior finalized ISP or Life
Plan, the Care Manager makes a note in the “Summary of IDT
Meeting” section of the Life Plan that there is a dispute
regarding that specific service, support, or goal, including a
narrative description of the nature of the dispute. Then the Life
Plan must be finalized, and the previously approved service,
support or goal must remain in the newly finalized Life Plan and
be implemented until the dispute is resolved. The CCO must
schedule a dispute resolution meeting with the IDT within fifteen
(15) business days to resolve the elements documented in the
“Summary of IDT Meeting” section of the Life Plan. If the dispute
resolution meeting is not successful and there are still disputed
elements in the Life Plan, the individual, their representative, or
the provider can initiate a 633.12 objection as outlined in 6.v
below.
b. If the disputed element represents a new service, support, or
goal that was not contained in a previously finalized Life Plan or
ISP, the Care Manager must remove the disputed service,
support, or goal from the body of the Life Plan altogether,
moving it into the “Summary of IDT Meeting” section, including a
narrative regarding the nature of the dispute. The Life Plan must
then be finalized. Because this is a proposed new service,
support, or goal, it is not required to be implemented pending
the outcome of dispute resolution. The CCO must schedule a
dispute resolution meeting within fifteen (15) business days to
resolve the elements documented in the “Summary of IDT
Meeting” section of the Life Plan. If the dispute resolution
meeting is not successful and there are still disputed elements
in the Life Plan, the individual, their representative, or the
provider can initiate a 633.12 objection as outlined in 6.v below.
ii. Within 45-days of the Life Plan meeting, the Care Manager and the
individual and/or their representative sign the Life Plan. With these
signatures, the Life Plan is considered final. Any disputed elements
remain in the “Summary of IDT Meeting” section and the remainder of
the Life Plan is ready for implementation. Disputed elements in a Life
Plan are NOT a reason for the failure of a party to finalize a Life Plan.
Finalizing or signing a Life Plan does not indicate agreement with the
documented disputed elements. Given that there exists a
mechanism for resolving disputes, after the disputed element is
documented or removed, as appropriate, the Life Plan must be
finalized and signed by the relevant parties.
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iii. The providers acknowledge the plan and agree to deliver the Provider-
assigned goals, supports, and safeguards associated with their
services, per the undisputed goals in the finalized plan (including the
prior version of currently disputed goals). The service provider’s
acknowledgement and agreement may be done via signature on the
Life Plan, Staff Action Plan, or a signed letter or other attestation. A
Life Plan must be acknowledged, even with element(s) in dispute but
disagreements will be noted.
iv. Staff action plans are developed and signed by the habilitation staff
and forwarded to the Care Manager via the CCO’s portal or another
agreed upon mechanism for prompt communication. In addition to
Care Managers, the Staff Action Plans should also be provided to the
individual and their representative and any other parties agreed to by
the individual and their representative.
v. Once the Life Plan and corresponding Staff Action Plans are finalized,
if an element remains in dispute and no agreement has been facilitated
by the Care Manager, then the individual, their representative, or a
provider may initiate due process proceedings pursuant to 14 NYCRR
633.12 as an objection to a plan of services. Care Managers should
inform the individual and their representative of any legal resources
they may have available to them to assist with the due process
proceedings (e.g., Mental Hygiene Legal Services).
During the pending due process proceeding, all other elements in the finalized Life Plan
and Staff Action Plans shall be implemented.
C. Suspension of Certain Billing Standards During the Transition Period
Notwithstanding the adjusted or suspended standards below, CCOs and
providers must arrange for necessary services and care for all enrolled
individuals.
1. Suspended Life Plan and Service Billing Standards
For Life Plans finalized on or before December 31, 2019 (i.e., the transition
period), OPWDD is suspending service documentation requirements for
documenting the Waiver service name, frequency, duration, and effective
date in the Life Plan. Instead, only the name of the service provider and the
service name must be identified in the Life Plan. Additionally, for Support
Brokerage services, the name of the Fiscal Intermediary (FI) must be
identified, but the name of the Support Broker/Agency that is paid by the FI
does not need to be included in the Life Plan.
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If the service provider or service being provided is not listed in the pre-
populated choices embedded in the Life Plan development system, the most
relevant choice available should be selected (e.g., “IRA” is acceptable in
place of Residential Habilitation, “Supported Work” is acceptable in place of
Supported Employment, etc.). However, Care Managers should identify the
correct service provider name and service name in the comments section of
the Life Plan to support provider billing claims.
All Life Plans created or amended after the transition period must
comply with all regulatory and policy standards.
2. Suspended Staff Action Plan Billing Standards
During the transition period, certain Staff Action Plan billing standards in ADM
#2018-09R are ONLY waived for individuals who have ISPs transitioning to
Life Plans. All non-waived billing standards remain effective for all Staff Action
Plans. Waived billing standards in ADM #2018-09R only include:
• “The initial Staff Action Plan must be in place no later than 60 days of the
start of the individual’s habilitation service, or the Life Plan review date,
whichever comes first;” and
• “Evidence demonstrating the Staff Action Plan was distributed no later
than 60 days after: the start of the habilitation services; the life plan review
date; or the development of a revised/updated Staff Action Plan,
whichever comes first (which may include, but is not limited to: a monthly
narrative note; a HITS upload; or e-mail).”
RECORDS RETENTION
All documentation specified above must be retained for a period of at least ten (10)
years from the date the service was delivered or when the service was billed,
whichever is later.
TECHNICAL ASSISTANCE
For questions regarding this memorandum, please contact the Office of Strategic
Initiatives and Division of Policy and Program Development at:
[email protected].
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Attachment A
Template for Documenting the Representative’s signature or approval of the Life
Plan.
Completed by the Care Manager
This template may be completed by the representative of (insert Name of Individual)
to document the agreement to the Life Plan effective (insert effective date of Life Plan
under review.
Representative Life Plan Attestation
By typing my name below, I am signing the above referenced Life Plan electronically.
I agree that my electronic signature is the legal equivalent of my handwritten
signature. I attest, that I agree to the provisions described in the Life Plan and serve
as the representative for individual identified above.
Signature of Representative (type name below)
Date
Template for Documenting the Provider’s signature or approval of the Life Plan.
Completed by the Care Manager
This template may be completed by the provider of (insert Name of Individual) to
document the agreement to the Life Plan effective (insert effective date of Life Plan
under review. This provider is identified as providing the following service(s): (List all
that apply)
Provider Life Plan Attestation
By typing my name below, I am signing the above referenced Life Plan electronically.
I agree that my electronic signature is the legal equivalent of my handwritten
signature. I attest, that my agency agrees to the provisions described in the Life Plan
as it relates to the provision of the above referenced services.
Signature of Provider Staff Person (type name below)
Date
Provider Agency Name