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Life Plan Resolution Process

for Provider Relations
  • Version
    2.0
  • Effective Date
    10/30/2019
  • Approved By

    Megan O’Connor-Hebert

    Vice President of Care Management

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1. Purpose

To define the policy and procedure at Care Design NY for the resolution of Provider concerns regarding Life Plans or the Life Planning Process in accordance with:
  • Section 1945(h)(4) of the Social Security Act
  • Care Coordination/Health Home (CCO/HH) Provider Policy Guidance Manual
  • Care Coordination/Health Home (CCO/HH) Provider Policy Guidance Manual Memorandum
    – September 2018 (Revised August 19, 2019)
  • OPWDD Administrative Directive – 2018-ADM-06R

2. Scope

The scope of this document focuses solely on concerns generated by provider agencies and delineates the procedures that representatives of Care Design NY will follow in attempt to resolve such concerns. Any potential change or amendment to a Life Plan must be acknowledged and agreed to by the individual/family involved and the Care Manager. Care Design NY will not make any revisions to a Life Plan without the agreement from the individual/involved family. All Care Design NY personnel are responsible for adherence to this procedure.

3. Definitions

  • Provider: any state or voluntary agency providing supports or services to an individual and is involved in the Life Planning process of a Care Design NY member.
  • Interdisciplinary Team: also known as the care planning team. The team of individuals who participate in the person-centered planning process and the development of an individual’s Life Plan. The team must be comprised of the individual and/or their family/representative, Care Manager, primary providers of developmental disability services and other providers, either as requested by the individual and their family member/representative. The team is expanded to include clinical experts where such input is needed.

4. Policy

The Life Plan and the Life Planning process must be conducted in a Person-Centered manner as outlined in the OPWDD Person Centered Regulations and Department of Health (CCO/HH Provider Policy Guidance Manual – July 2018).

Providers are a critical part of the Life Plan Interdisciplinary Team (IDT) and should be actively involved in the Life Plan meeting and subsequent communications regarding the individual supported.

All parties are encouraged to work collaboratively and well in advance of the required time-period for Life Plan finalization.

It is anticipated that through open communication, most concerns will be able to be resolved at the Life Plan meeting.

In situations where resolution is not made at the meeting or a concern is raised or identified after the meeting, the following procedure should be followed.

5. Proceedure

5.1

Facilitating Resolution of Provider Concerns
The Care Design NY Care Manager will work with the individual/family and the IDT to facilitate potential resolution to the Provider's concerns where possible. The Care Design NY Care Manager should make their Supervisor aware of any unresolved Provider concerns regarding the Life Plan and make appropriate adjustments to the Life Plan (See Life Plan SOP).

5.1.1

If the concern is not resolved or cannot be resolved during the Life Plan meeting, the Provider should contact the Care Design NY Care Manager Supervisor or another member of the Regional Care Management Team (Senior Care Manager Supervisor or Care Manager Director) to discuss the concern along with any proposed revisions or remedies.

5.1.2

The Care Design NY Care Manager should also inform their management team of any unresolved Life Plan concerns that the Provider may have, along with specific information including who is involved from the Provider's agency, the nature of the concern along with the reason that it has not been resolved.

5.1.3

The Care Design NY Care Management representative from the Regional Care Management Team will contact the Provider to discuss the concern and where necessary, a meeting will be arranged with the goal to resolve the Provider’s concern. Due to the time sensitive nature of finalizing and publishing the Life Plan, every effort will be made to hold this meeting within five business days.

5.1.4

If the Provider is not satisfied with the outcome of their meeting/communication with the Care Design NY Management representative, the Care Design NY Regional Care Manager Director should be contacted to assist with the resolution 5.1.4.1.

The Regional Director will consult with the Assistant Vice President of Care Management and depending upon the seriousness of the disagreement, additional representatives of Care Design NY leadership may provide advisement on the concern of the Provider (e.g. Vice President of Compliance, etc.)

5.1.5

In extremely rare situations, a Provider may still disagree with the handling of their Life Plan concern despite the attempts that have been taken to resolve any disagreement. Upon written request from the Provider agency's Chief Executive Officer (CEO) to the Care Design NY Vice President of Care Management or CEO, Care Design NY will seek guidance, as needed, from the Regional Office for People with Development Disabilities (OPWDD), the Department of Health (DOH) or a relevant outside agency within two business days. In cases where a Provider's concern is not able to be resolved through the above procedure, the Care Manager will document the Provider's concern as part of the Life Plan publishing process. Within 45 days of the Life Plan meeting, the Care Design NY Care Manager and the individual and/or his/her representative will sign the Life Plan.

5.1.5.1

With these signatures, the Life Plan is considered finalized. Any disputed elements will remain in the “Summary of IDT Meeting” and the remainder of the Life Plan will be ready for implementation.

5.1.5.2

The Provider will 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 – if applicable, of currently disputed goals.) The Provider's acknowledgment and agreement may be done via wet signature, email, Life Plan acknowledgment within the plan, or other method agreed upon between the Care Manager and the service Provider.

5.1.5.3

A Life Plan must be acknowledged, even with element(s) in the dispute, but disagreements will be noted in the “Summary of IDT” minutes. Staff Action Plans (SAP’s) are developed and signed by the habilitation staff and forwarded to the Care Design NY Care Manager. The SAP’s are also required to be provided to the individual and his/her representative and any other parties agree to by the person and his/her representative.

5.1.5.4

Once the Life Plan and corresponding SAP’s are finalized, if an element remains in dispute and no agreement has been facilitated by the Care Manager, then the individual, his or her representative, or a Provider may initiate due process proceedings pursuant to 14 NYCRR 633.12 as an objection to a plan of services.

5.1.5.5

During the pending due process proceeding, all other elements in the finalized Life Plan and SAP’s shall be implemented.

6. Responsibility

  • Employee Responsibility
    The Care Design NY Care Manager will work directly with providers to resolve concerns that arise in the course of Life Plan development or Life Plan meetings.
  • Supervisor Responsibility
    Care Manager Supervisors, Senior Care Manger Supervisors, Care Manager Directors, Care Manager Regional Directors will provide guidance and assistance to Care Managers in the handling of provider concerns.

Reference Documents

List of applicable reference documents. Include associated Regulations, Policy, SOP’s, Standards, monitoring records

Document Name

  • OPWDD – 2018-ADM-06R
  • OPWDD CCO/HH Policy and Procedure Guidance Manual
  • Section 1945(h)(4) of the Social Security Act
  • Care Coordination/Health Home (CCO/HH)
    Provider Policy Guidance Manual Memorandum
    September 2018 (Revised August 19, 2019)
  • Life Plan SOP
  • Staff Action Plan Program & Billing Requirements
    ADM 9/2018

Revision History

  • Revision Summary
    Author
  • Policy and Procedure Manual | 10/29/19
    J. Clearly
    Updated to include guidance from 2018-ADM-06R, added appropriate definitions, added additional references, added additional purpose guidance, updated CDNY to Care Design NY throughout.

Please note that this policy will be reviewed and revised as needed. In the event this policy is revised, Care Design NY will provide notification to all employees of such revisions. For the most current version, please refer to the version available electronically online with SharePoint.

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Compliance Hotline

1-877-382-2942

This number is to be used by anyone to report a suspected violation of the code of conduct, compliance guidelines, operational policies, a law or regulation, or other concern to the compliance offices

Corporate Office Location
  • 8 Southwoods Blvd, Suite 110
    Albany, NY 12211
  • (518) 235-1888
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Suite 110
Albany, NY 12211

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