NY Manual
SHP Manual

SHP Provider Manual
3.7 Covered, Coordinated and Non-Covered Services | 4.1 Network and Provider Relations

3.8 Assessments of Members

The member must be determined eligible for long-term care services (CBLTCS)* by the Conflict Free Evaluation and Enrollment Center (CFEEC) before joining a Managed Long-Term Care Plan like Senior Health Partners. Once the member is determined eligible, the member has sixty (60) days to select a Managed Long-Term Care Plan like Senior Health Partners for enrollment.

The CFEEC is a statewide resource that will provide independent and conflict-free evaluation, education and enrollment services for new applicants in need of community based long-term care services.  In New York, Maximus (New York Medicaid Choice) serves as the independent and conflict-free entity. This policy does not apply to individuals transferring from one plan to another or from one Managed Long-Term Care product to another. All new Managed Long-Term Care enrollees may contact the CFEEC at 1-855-222-8350. The member may call anytime Monday to Friday, 8:30 am to 8:00 pm or on Saturday, 10:00 am to 6:00 pm.
 
Once New York Medicaid Choice determines that a consumer is eligible for community based long-term care for more than 120 days, the consumer can choose a Managed Long- Term Care Plan. The consumer has several weeks to select a plan; however, the CFEEC evaluation will remain valid for 60 days. After such time, a new evaluation will be required if the consumer does not select a plan but continues to seek CBLTC.
 
Enrolling in Senior Health Partners is voluntary. If the member is interested in joining Senior Health Partners, the member or a member's representative can call Senior Health Partners and our staff will assist clients new to Managed Long-Term Care in contacting New York Medicaid Choice to find out more about our program. If the member is 21 years of age or older, lives in our service area, has completed a New York Medicaid Choice evaluation, and has chosen Senior Health Partners, our Enrollment Medicaid Specialist will come to the member's home to share more information about our program, at which time we will be able to collect more information about the member and their health care needs. The member may have a family member, or anyone else the member may wish, present when the Enrollment Medicaid Specialist comes to their home. If the member is still interested in joining Senior Health Partners after our Enrollment Medicaid Specialist has described the program to the member, our Enrollment Medicaid Specialist will confirm their Medicaid eligibility.
 
  • Medicaid eligibility must be reviewed and established for potential enrollees by the NYC Human Resources Administration or Local Department of Social Services
  • If the member does not currently have Medicaid, we will help the member apply for Medicaid coverage unless the member is a private pay member
  
Our Enrollment Medicaid Specialist will:
  • Ask the member to sign an authorization for intake and nurse assessment, which allows the Clinical Eligibility Nurse to assess their healthcare needs and clinical eligibility
  • Ask the member to sign a consent form that allows their healthcare providers to release their medical information to us
  • Review the Member Handbook with the member
 
Our Clinical Eligibility Nurse will come to the member's home within 30 (thirty) days of the request to join Senior Health Partners or upon referral from the CFEEC to:
  • Conduct an initial assessment
  • If the member has Medicaid only, the initial assessment will determine if the member is eligible for nursing home level of care as required for enrollment
  • Determine if the member requires community-based long-term care services offered by Senior Health Partners for more than 120 days
  • Provide the member with information and the form regarding electing a Health Care Proxy
  • Discuss the service needs with the member
 
 After completing the initial assessment, our Clinical Eligibility Nurse will ask the member to sign the Enrollment Agreement. By signing the Enrollment Agreement the member agrees to:
  • Receive all covered services from Senior Health Partners and our network providers
  • Participate in Senior Health Partners according to the terms and conditions described in the Member Handbook
 
During the time prior to their enrollment, the Welcome Team social worker will maintain contact with the member to answer any of their questions, discuss the Person Centered Service Plan (PCSP), and help the member with any service needs prior to their enrollment date.
 
A member's enrollment becomes effective on the first of the month. The member will receive their membership letter and a Senior Health Partners membership identification card.
Following enrollment, their Primary Care Management Team will contact the member to review their satisfaction with the PCSP and discuss any concerns the member may have.  Changes in the PCSP can be made as needed based on the member's needs. The Primary Care Management Team will ask the member, their physician and their family/caregivers for input in development of changes in their PCSP.  If the member's services have been changed, the member will receive a letter explaining the change.
 
The PCSP changes as the member’s needs and condition change, and is re-evaluated at least every six (6) months.