The following letter (PDF here) was sent to Governor Hochul to urge a delay of the transition to a single statewide fiscal intermediary for the Consumer Directed Personal Assistance Program (CDPAP):
We are CDPAP consumers, their families and advocates, asking you to slow down the transition to a single Fiscal Intermediary (FI). Whether through executive action or the upcoming state budget process, the March 31, 2025 deadline for about 250,000 consumers and 400,000 personal assistants (PAs) to transition is unrealistic and must be extended. Otherwise, disruption of vital life-saving home care services will be inevitable, leading to accidents and medical crises, hospital admissions, and forced nursing home placement—in violation of the integration mandate of the Americans with Disabilities Act (ADA) under the U.S. Supreme Court Olmstead ruling.
Given the experience of other states, a minimum of two years is essential to avoid disruption of services. Pennsylvania transitioned from 36 FIs down to one in 2013. There, only 22,000 consumers were supposed to be transitioned—less than ten percent of the number in New York State. Yet, even with that small population, about one-third of consumers failed in making the transition and lost services. Thousands of PAs were not paid, in some cases for months and quit.[1] In January 2024, Massachusetts set a timeline of 19 months to transition just 70,000 caregivers in its program to a new single FI. In stark contrast, New York’s timeline of only three to four months to transition over 250,000 consumers and some 400,000 caregivers is both unrealistic and risky to the disabled people the program is designed to support.
There are myriad reasons why the transition steps may not be completely taken for 250,000 consumers within less than three months. Pennsylvania’s experience in 2013—again with a much smaller cohort transitioning—showed some of the problems that can prevent a smooth transition. Incomplete or inaccurate information was transferred to the single FI, some consumers and PAs had to transfer twice after a glitch on the first try, and thousands of PAs were not paid consistently on time or at all. See fn. 1. Pennsylvania made a second FI transition in 2022, which added confusion about how to use the new electronic visit verification (EVV) and time approval systems. Lack of testing of payroll portals with consumers led to problems and delays. See fn 1. We are concerned similar problems will accompany New York’s transition. For example, PPL has stated the online system can support only 300 consumers at a time, yet 250,000 consumers must transition over a three month
period. The Department must work toward an administrative or legislative pathway to create a roll-out that affords time to ensure these critical enrollment systems will not be overloaded.
The initial guidance that the State Department of Health has posted along with the information on the PPL website raises additional questions regarding the feasibility of this short time frame. For example:
- Data Transfer from FIs — The state policy requires the current FIs to record detailed information about each consumer and PA on an Excel template by January 15, 2025.[2] A separate template must be completed listing the consumers served by each MCO, MLTC and LDSS with which the FI contracts. There are 27 data fields for each consumer. The plans and LDSS are then supposed to aggregate the data from all the FIs and send it to DOH within one week by January 22. This timeline is unrealistic. Even FIs with electronic databases that contain the needed information would have to design a program to export the data as required for the State template. Others would have to manually enter the data. Many FIs are losing staff as employees learn their jobs will end by March 31. While a burden to the FIs, it is the consumers who will be harmed by inevitable delays in transferring data to the State, and in turn to PPL. Further, this rollout provides insufficient time for the DOH to review the data for quality assurance purposes.
- Initial notices to consumers lack assurance they will be contacted to provide assistance with the transition. The DOH December 6, 2024 Consumer Directed Personal Assistance Program (CDPAP) Statewide Fiscal Intermediary Transition Policy for Current Fiscal Intermediaries (hereinafter “FI Transition Policy”) states that the notices that the current FIs are required to send to consumers indicate “that the SFI will be contacting them to assist them with the transition process.” But the notice template instead lists three options for steps the consumer must proactively take to make the transition, with no assurance they will be contacted by the SFI. See https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/2024/docs/fi_transition_template_fi_to_consumer.pdf. Without individualized outreach by the SFI, many consumers will fail to transition to PPL. Any mailings to consumers from PPL must allow sufficient time for the mail to arrive and to be reviewed by the consumer and/or their designated representative. These letters should be received before March 1 to give consumers any chance of completing the transition by March 28. Failure to enroll in PPL by March 28, without a continuity of care policy, will result in the critical loss of services. Some consumers will require emergency department care or hospitalization. Others may lose their PAs who will seek employment elsewhere so as not to forgo income. Finally, we also question whether the FIs, who must cease to exist after March 31, 2025, are the best messengers of this systems change. These letters should be supplemented by a letter from the Department of Health.
- Lack of language access and clear policies to ensure access for members with cognitive or other impairments. The DOH policy does not state that the notice templates must be sent in the consumer’s language, even though English is the primary language for only 38.3% of all MLTC members.[3] We are also concerned about people with dementia or other cognitive impairments. The percentage of MLTC plan members with intact cognitive function ranges from 23 – 53%. See n. 1 at pp. 20-21. There is nothing in the State’s procedures requiring PPL, the FI or the Plans to reach out to the designated representatives of consumers who, because of cognitive or physical impairments may be unable to cope with these requirements.
- Lack of comprehensive complaint system for consumers. All letters to consumers should include a telephone complaint line staffed by the Department of Health. Such telephone complaint lines were created for the NYRx transition as well as the NYIAP transition. Relying on PPL’s own hotline as the sole avenue for complaints is not sufficient. Also, DOH should consider listing the managed care ombuds program phone number on these notices. We also request that the Department post the complaint phone number and email address widely, in at least the following locations:
- Readiness Review — The Pennsylvania audit of the 2013 transition to PPL of only 20,000 consumers describes a detailed readiness review by the State which raised flags showing that more time was needed for the transition. For example, since PPL is only now staffing up its call center, how will DOH test its capacity to field the high volume of calls expected? DOH must conduct a readiness review of all of the same systems tested in Pennsylvania, and be able to ensure continuity of coverage with the current FIs past March 31, 2025 if systems are not ready. See n. 1 at pp. 29-31.
Notice to the Consumer and a Backup System to Ensure Continuity of Care is Essential
The messaging from PPL and the State is that CDPAP services will simply end on March 31, 2025, for consumers who have not transitioned to the SFI by March 28. This is unacceptable and would be a gross violation of Due Process. Consumers must be given advance 10-day notice before services are discontinued, with the determination they have allegedly failed to take whatever steps are required. The consumer could have attempted to contact PPL but reached overloaded phone lines, or have mailed or emailed documents that were not received or processed. The State is placing the onus of the transition on consumers, and consumers have the due process right to notice of a determination that they have not met that burden.
Further, development of a back-up system will necessitate a system by which PPL reports to DOH on a verified number of consumers who have transitioned to the SFI. This must include a transition of payroll, EVV enrollment, plan of care, and other steps. DOH would then cross-check that list with the list of all consumers compiled from the plans’ and DSS’ reports made by January 25, 2025. PPL should report to DOH regularly. However, to preserve continuity of care, the last verification must come to DOH at least 15 days before March 31, 2025. DOH would provide that list of consumers whose transition is not completed to the plans and DSS, and they would then be required to continue services with the existing FIs for at least 90 days or earlier, if PPL confirms and the Department verifies that the transition is complete. This would afford some minimal time for plans to conduct outreach to their members and facilitate the transition.
Ongoing Public Communications with Stakeholders
We request that the Department hold public stakeholder telephone calls for consumers, advocates, plans and FIs beginning immediately. The Department should report on the status of the transition and assist and advise stakeholders as necessary. Data on transitioned consumers by region and product should be reported publicly to stakeholders beginning the week of January 13, 2025.
We appreciate the opportunity to put our ongoing concerns in writing and we remain available to discuss this transition.
[1] Commonwealth of Pennsylvania, Department of the Auditor General, Performance Audit: Department of Public Welfare’s Oversight of Financial Management Services Providers, November, 2013, available at https://www.paauditor.gov/Media/Default/Reports/speDPWPPL111413.pdf.
[2] Template available at available at https://www.health.ny.gov/health_care/medicaid/redesign/mrt90/2024/docs/cdpap_fi_data_transfer_template.xlsx.
[3] NYS DOH 2022 MLTC Report at page 9, available at https://www.health.ny.gov/health_care/managed_care/mltc/pdf/mltc_report_2022.pdf