XVI. CCO Provider Policy Manual: Life Plan

The Life Plan is the OPWDD Person-Centered Service Plan, created using the person-centered planning process and required by 14 NYCRR Part 636.

The Life Plan is the blueprint for achieving a person’s Valued Outcomes (e.g., meaningful goals). It is a flexible informational tool used to focus and direct efforts to assist the person throughout their lives. It is a readable and usable written plan that reflects the informed choices of people with developmental disabilities. CCO/HHs work with individuals and their families/representatives to bring together health care, social services, and developmental disability service providers to develop an integrated Life Plan that includes developmental disability, medical, behavioral health, community and social supports, and other services. CCO/HHs must ensure that the Life Plan includes all support needs, services, and safeguards identified by the initial and annual comprehensive assessment process.

Such documentation must provide a holistic view of the person including but not limited to:  medical/health documentation, psychological evaluations, assessments, plan of nursing services, behavioral support plans, habilitation needs, safeguard needs, Staff Action Plans, referrals for services and potential providers, and Social Service applications.

CCO/HHs and Care Managers must first understand the content and expectations outlined in the following sections of this Policy Manual before developing the Life Plan:

• Enrollment
• Comprehensive Assessment
• Person-Centered Planning
• Face-to-Face (FTF) Care Management Contact Requirements

In addition to understanding these sections, Care Managers must also be familiar with HCBS Settings criteria to ensure that individuals receive Medicaid HCBS in settings that are integrated in and support full access to the greater community and that it is reflected in their Life Plan.

For all new CCO/HH enrollees, the initial Life Plan must be finalized no later than (90) days after the person’s enrollment in the CCO/HH (see requirements for finalization below).

The development of an initial quality Life Plan requires the Care Manager to get to know the enrollee and their chosen circle of support. This helps create a positive relationship between the Care Manager, the individual, and the care planning team. This process should include as many conversations and care planning meetings as needed to ensure that the initial Life Plan is developed and driven by the enrollee. The initial Life Plan must also include the person’s needs, fully reflect who the person is, and identify what they want to achieve.

If a person chooses to transfer to a different CCO the receiving CCO should receive the person’s current Life Plan and associated documents and, with the person’s and Care Planning team’s agreement, can continue with the current Life Plan cycle. See the Disenrollment and Transfer section for more information. 

The Care Manager is required to develop a Life Plan with the person in accordance with 14 NYCRR Part 636 Person Centered Planning Requirements. The Care Manager must develop the Life Plan in a way that is understandable and accessible to the individual and parties chosen by the person. The Life Plan must also be translated into the person’s/authorized representative’s/legal guardian’s primary language. A person’s primary language should not be assumed. The primary language is decided by the person and/or their family/representative.

Person-Centered Approach and Role of Care Planning Team:

The Care Planning Team is the team of individuals who participate in the person-centered planning process and the development of a person’s Life Plan. The team must be comprised of the person and/or their family/representative, Care Manager, primary providers of developmental disability services and other providers either as requested by the person and their family member/representative. At least one (1) of the Life Plan meetings must include all Developmental Disability service providers and others as necessary and agreed upon. 

For those who do not have any natural unpaid supports, the CCOs must be working with the person and Care Planning team on community inclusion strategies that could lead to meaningful relationships in the person’s life if desired by the person.

A person-centered approach must be used in the development and review/revision of a Life Plan. This is the care planning team’s opportunity to listen to the person’s perspective and discover and focus on areas of the person’s life that may need special attention and are meaningful to the person. In order to do so, the person’s care planning team must be organized and prepared to review, share, and update necessary information, documents, and reports to best support and advocate for the person.

The Care Manager must facilitate the coordination, planning, information sharing and scheduling far enough in advance of the actual Life Plan meeting to ensure full participation of all care planning members and to help ensure that the actual meeting is efficient, productive, and focused on the person and what he/she wants to discuss and his/her progress in goal achievement. The care planning team should consider whether service strategies need to be adjusted to optimize the person’s development and progress during the meeting. It is essential that the Care Manager reach out in advance of the meeting to work with the person to establish his/her agenda for the meeting and to coordinate with all required members of the Care Planning team and other person(s) that the person chooses to invite to the meeting and to obtain needed information in advance of the meeting. In addition, any written translation of written materials and/or the scheduling of a professional interpreter should be done far enough in advance of the Life Plan meeting to ensure full participation of all care planning members. Language access best practice is to translate written documents and schedule oral interpreters at least two weeks or more in advance of the meeting.

The person leads the planning process to the extent they are willing and able to do so. It is the responsibility of the Care Manager to support the person to facilitate his/her meeting to the extent he/she prefers and to also ensure that all relevant and pertinent information gathered from habilitation providers and others involved in the person’s care is reviewed to inform development of the Life Plan prior to or during the Life Plan meeting.  

The following items must be used, if applicable, for the person’s care:

1. OPWDD approved functional needs assessment
2. Medical/health status;
3. Plan of Nursing Services;
4. Behavioral Support Plans;
5. Medication updates/changes;
6. Habilitation needs;
7. Safeguard needs;
8. Staff Action Plans; and
9. Other information, including updated assessments, pertinent to the person’s development and progress in addressing needs and goals.

This section describes the required components and sections of the electronic and printed Life Plan and what must be specifically documented in each section.

CCO/HHs may develop their own electronic and printed Life Plan template as long as it contains the following minimum sections and elements/fields and documents the required information:

Demographics Section

This section of the Life Plan captures identifying information about the person, including the following fields below. The information can be listed within the demographics or any section as long as it is captured in the Life Plan.

1. Full name
2. Medicaid number or CIN number,
3. Medicare number if applicable,
4. OPWDD Tracking and Billing System (TABS) number,
5. Date of birth,
6. Person’s address,
7. Person’s telephone number,
8. The CCO/HH in which the person is enrolled,
9. Name of lead CCO/HH Care Manager
10. Telephone number/contact information for lead Care Manager
11. Name of person’s representative, advocate, legal guardian, custodial party(ies) authorized representative(s) and contact information if applicable
12. Primary language – spoken, written, and understood
13. Willowbrook Class Member (Yes or No)
14. CCO enrollment date (enrolled in the specific CCO referenced)
15. 24-hour contact number for the CCO

The CCO and Care Manager information must be easily identified within the Life Plan including the CCO name and address for which the person is a member, his/her Care Manager’s name along with the Care Manager’s phone number and email address. It is also recommended to include the 24-hour emergency contact number for the CCO in this section of the Life Plan.   

The Life Plan, and the services described in it, 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 DDRFO for the individual).

Lastly, the Life Plan must include the Meeting History pertaining to this Life Plan including date of the meeting and reason for the meeting/meeting type including whether it is an Annual Meeting, Semi-Annual Review meeting, or other meeting or review type. 

Whenever a Life Plan is created or revised, it must be finalized and agreed to with the individual’s written informed consent and signature of the Care Manager (within 45 days of the Life Plan meeting) and signed by the provider(s) responsible for implementing the Life Plan (provider signatures may occur after finalization of the Life Plan).

“Signed” by the individual means that the individual provided written informed consent to their Life Plan. This written informed consent can take the form of a physical signature which can also be a scanned signature, a digital signature, or an e-signature.

If the individual is incapable of signing the Life Plan, the following 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 invert in technology capable of using technology that has a verbal signature capability.

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 alternative 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.

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 representative if applicable must be retained with the applicable Life Plan and made available upon review by NYSDOH, OPWDD or external audit entities.  It must also be distributed with the finalized Life Plan to providers and other relevant parties responsible for implementation of the Life Plan.  

Providers responsible for delivering services documented in Sections II and III of the Life Plan must sign the Life Plan to acknowledge and agree to provide the provider-assigned goals, supports, and safeguards associated with those services, per the agreed upon plan.

The service provider’s signature indicating acknowledgement 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 Section 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 and 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.

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 DDRFO for the individual).

It is a best practice to provide a draft Life Plan with the Actions/Provider Assigned Goals to providers as soon as possible after the Life Plan meeting. Habilitation service providers need the Life Plan to facilitate completion of the required Staff Action Plan (SAP).

Also, the annual LCED redetermination must be distributed with the Life Plan and is available electronically through CHOICES.

New Services Prior to Life Plan Finalization:

Some individuals are in time-sensitive situations and will need HCBS waiver services authorized prior to enrollment in a CCO and prior to finalization of a Life Plan.  These individuals may apply and be authorized for HCBS waiver services prior to meeting CCO eligibility and enrollment requirements. The CCO and OPWDD DDRFO must work together to ensure that all required eligibility documents are provided to address timely access to HCBS waiver services and to support service authorization for HCBS waiver services.

When an individual needs authorization for OPWDD HCBS waiver services, the OPWDD Regional Office must be provided with documentation to support/justify why services are being requested. A finalized or an In-Process Life Plan satisfies this requirement. Individuals seeking services offered through OPWDD’s HCBS Waiver must demonstrate a reasonable indication of need as outlined in 23-ADM-06.

An In-Process Life Plan is a Life Plan that is under development and has not yet been finalized but contains adequate information to support the need for the requested service(s). An In-Process Life Plan must be signed by a person who meets the qualifications of a Care Manager employed by the CCO.  An In-Process Life Plan does not have to be signed by the individual/representative, nor does it have to identify service providers. A properly written In-Process Life Plan may qualify as a Social Evaluation for purposed of the Initial Level of Care Eligibility Determination (LCED) if it contains all the required elements of a social Evaluation as described in 20-ADM-04.

The Life Plan or In-Process Life Plan, submitted for the purpose of a new service authorization or a service amendment request, must be submitted with the completed Request for Service Authorization (RSA) or Service Amendment Request Tool (SART) and contain detailed person-centered information describing the individual’s skills, abilities, reasonable accommodation, cultural considerations, meaningful activities and challenges as they relate to their home, work, relationships, health and (as applicable) educational profile. The Life Plan or In-Process Life Plan must contain enough detail to support the need for the requested service(s). In addition, the RSA or SART must contain a brief description justifying the need for each service listed and/or identify specifically where the justification is found within the submitted supporting documents.  The OPWDD Regional Office may also request additional information and/or documentation if it is determined that the Life Plan or In-Process Life Plan does not contain enough information or if there are elements missing from the Plan to support the need for the requested service(s). Additional documentation requested may include, but is not limited to:

• Documentation related to eligibility, the Waiver application and /or the Level of Care Eligibility Determination (LCED), including psychological or psycho-social reports;
• Individual Education Plans (IEP) and 504 Plans;
• Discharge plans developed by hospitals, nursing homes, correctional facilities, etc.;
• Assessments (e.g., clinical assessment(s), CAS/CANS summaries; Comprehensive Assessment Tool summary)
• Service planning packages developed during Intermediate Care Facility (ICF) to Individualized Residential Alternative (IRA) conversions;
• Preliminary Adult Service Plans developed by a provider planning for an individual to leave a residential school; and
• Other additional information requested by OPWDD.

When HCBS Waiver services are needed prior to the finalization of a Life plan, an RSA and SART approved by an OPWDD Regional Field Office, along with the acceptable documentation, as outlined above justifying the need for services is sufficient documentation to support service authorization for service billing purposes. HCBS Waiver providers must continue to follow all HCBS Waiver service documentation and billing standards and requirements. 

The requirement of a life plan or in-process life plan may be waived by OPWDD in emergency situations where the OPWDD Regional Office Director or Designee determines an individual has an urgent need for immediate services and requiring a Life Plan would cause undue delay of access to services and supports required to ensure the individual’s health and safety. If the need for a Life Plan or In-Process Life Plan is waived by OPWDD, the CCO must still submit supporting documents, as outlined above, that support the service request. 

The individual’s life plan includes periodic reassessment and ongoing monitoring of the individual’s needs and clearly identifies the individual’s progress in meeting goals and changes in the life plan based on changes in individual's need. Monitoring activities must review and document the status of the person in relationship to the stated goals and anticipated outcomes.

Monitoring expectations include the need for ongoing care manager review of each individual’s status through, but not limited to, the following activities, commensurate with the stability of the individual:

1. Discussion with the person/representative and/or observations in their home or program,
2. Review of assessments available or completed relative to particular need areas
3. Review of medical, clinical, and legal documents
4. Meetings and/or discussions with service providers
5. Review of Regional Health Information Organization (RHIO) alerts and relevant related information
6. Completion of follow up with clinical and health care providers

The goal of monitoring the individual is to resolve any gaps in supports and services or instability in their ’circumstances. This monitoring must be ongoing. Monitoring actions must be documented comprehensively in the EHR.     

The Care Manager is responsible for facilitating the implementation of the finalized Life Plan and ongoing monitoring. This includes, but is not limited to: 

1. Making referrals and executing the needed linkages to service and support providers;
2. Monitoring the provision of needed services and supports and whether effective in meeting the persons needs and goals;
3. Coordinating care;
4. Facilitating communications among the individual and care planning team including needed contacts with service and support providers to monitor progress and address challenges;
5. Ensuring continuity of care;
6. Proactively addressing any challenges and/or obstacles that arise;
7. Ensuring the Life Plan is written and kept in the primary language of the person and family members;
8. Conducting follow-up;
9. Reviewing medical and behavioral consultation information and updating the Life Plan as needed to align with recommendations and ensuring appropriate services/supports are in place based on this information; and
10. Communicating with the person’s physician’s office (and other medical and behavioral health providers) as needed. This is to ensure that the Life Plan matches the physician’s assessment of the individual’s needs. 

The required Annual and Semi-Annual Life Plan Reviews, and other ongoing Life Plan reviews as needed, are important to ensure: 

1. Implemented Life Plan is effective and appropriate in supporting the person in making progress towards meeting their needs and goals and making changes as needed;
2. Person is satisfied with their plan;
3. Services/supports are meeting the individual’s needs, addressing challenges, barriers and obstacles, and mitigating risk;
4. Person has opportunity to identify if they would like to make any changes to their plan;
5. Whether service/support providers have noted any challenges that should be addressed in the Life Plan; and
6. The monitoring of progress, development, and outcomes for the person.

Review, monitoring, and revision of the implemented Life Plan when needed is critical to ensuring that the individual’s needs are being met and that they are making the desired progress towards goals that contribute to a meaningful life as they define it. To accomplish this, it is necessary to evaluate whether service and support goals and service delivery strategies are having the desired effects to determine whether changes are needed to facilitate progress and to address challenges.

The individual, parties chosen by the individual, the service providers, and Care Manager must formally review the Life Plan and the Care Manager must revise such plan (if necessary) a minimum of twice within a 12-month period (formal reviews are recommended every six months). Reviews are to be conducted in the primary language of the person and their support team members, using a professional interpreter as needed or requested, and any changes are to be made and delivered in the primary language, using professional written translation services as needed.

The CCO/HH supports care coordination and facilitates the establishment of regular case review meetings (i.e., Life Plan review), which includes all members of the care planning team on a schedule determined by the person and the CCO/HH. At a minimum, the schedule for the Life Plan review will, in most cases, follow the person’s established schedule for annual care planning meetings, which requires the plan is reviewed and updated at least twice each year in the primary language identified by the person and their family/representatives that they can speak, read, and understand. During periods of instability or changing needs or as desired by the person, additional care planning meetings should be facilitated to identify what supports and services are needed to enhance progress and improve outcomes. The planning should identify clear expectations related to provider roles and responsibility for proactive and responsive actions to address issues. The CCO/HH provider has the option of utilizing technology conferencing tools including audio, video and /or web deployed solutions when security protocols and precautions are in place to protect PHI (Personal Health Information) and it is desired by the person and in their best interest, not for convenience of Care Managers or Providers.

If the individual has unique characteristics that are important for the receiving service/program to know, such as involvement with social services, high-risk and/or unstable, periods of non-compliance with recommended treatment, or any other risk status, the CCO must notify the receiving entity of those risks and establish effective communications for collaborating on action planning.

Life Plan Reviews:    

Annual in-person Face-to-Face Life Plan Review meeting: must occur no later than annually or by the end of the calendar month in which the annual date occurs.

Semi-annual Life Plan Review: a routine review of the individual’s Life Plan that occurs during the year.

For additional information related to meeting requirements see Face-to-Face (FTF) Care Management Contact Requirements

In addition, formal Life Plan reviews must occur:

1. When the capabilities, capacities, or preferences of the individual have changed and warrant a review;
2. At the request of the individual and/or parties chosen by the individual;
3. When it is determined that the existing plan (or portions of the plan) is/are ineffective; and
4. Upon reassessment of the individual’s functional need or when there is a significant change in the individual’s functioning.

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.

If a provider identifies an inaccuracy in the Life Plan, the Care Manager must be responsive and work with the provider and the person/representative to determine if this issue requires an immediate update to the Life Plan or can wait until the next Life Plan Meeting per the above guidance.

When to Update the Life Plan (Life Plan Addendums)

CCO/HH Care Managers are required to keep the Life Plan up to date and continually review the individual’s preferences, goals, need for supports and safeguards, effectiveness of the Life Plan and service delivery support strategies, etc. as part of comprehensive care management and monitoring the implemented Life Plan.   

The ultimate purpose and goals for this activity is to ensure that the individual’s supports and services are meeting the person’s needs and contributing to a meaningful life for the person as he/she defines that through their chosen goals and that any health, behavioral, or other challenges and obstacles are being proactively addressed and monitored and good health is promoted.   

The Life Plan must be revised whenever there are significant changes.

Significant changes include, but are not limited to: 

• A change in a goal;
• Support changes;
• Service changes;
• Changes in the provider delivering a support or service;
• Life event changes such as a move to a new setting or loss of a caregiver;
• Changes in safeguard needs (e.g., medication administration, support services following hospitalization discharge, or other changes due to sites of care); and
• Significant changes in a person’s condition.

The Life Plan must be reviewed and revised if ineffective per 14 CRR-NY 636-1.3 Person-centered Service Plan and standard number 11-9 of the PCR Manual. Changes must be made when the implemented Life Plan is not achieving the desired results for the person; when goals/supports are not effective and need revision in order for the person to make progress towards their goals.

Immediate Life Plan Update:

The Life Plan must be revised prior to the next Life Plan review whenever there are significant changes to the individual’s Life Plan including but not limited to:

1. Significant change in condition (SCIC), that results in changes to a person’s functional status, as defined in the Comprehensive Assessment Section.
2. A change in a safeguard
3. Substantial change in a goal, support, or service.
4. A change in the provider delivering a support or service.
5. Sentinel events (unanticipated event) or life changing events, such as a move to a new setting or loss of a caregiver, that results in an immediate change to the person’s supports and services.

In addition, the Care Manager must consider a person’s current services, supports or living situation to ensure review and updates of associated plans and assessments and any necessary referrals.

As noted in the Comprehensive Assessment section, if the Care Manager determines that an SCIC has occurred, they must refer the person to OPWDD for reassessment with the OPWDD state-approved functional needs assessment (e.g., CANS, CAS, DPP2). 

Updates at the Next Scheduled Life Plan Review:

Circumstances that do not require an immediate Life Plan change and can therefore wait until the next formal Life Plan review include:

1. Short term events such as a temporary illness or temporary change to the person’s health, temporary location change, etc.
2. A provider/natural support address or name change, Agency merger;
3. If an element of the Life Plan is not achieving the desired results for the person;
   • meaning: when a goals/support is not effective and needs revision for the person to make progress. These updates should be made by the next review (annual or semi-annual).

These circumstances must be addressed immediately by the providers and communicated effectively to the Care Manager and care planning team and vice versa. However, they do not require an immediate Life Plan change and can therefore wait until the next formal Life Plan review if a Life Plan revision is necessary. Any changes or issues raised or addressed must be documented in the person’s care management record as part of the monitoring functions of the Care Manager.   

No Life Plan Update Needed:

Time limited events, such as sedation, flu, or brief illness, do not require a Life Plan change. However, brief changes may need to be communicated timely to the Care Manager, providers, and care planning team. These changes must also be documented in the care management record.

Life Plan Updates Upon request:

The Care manager must revise the Life Plan, if necessary, at the request of the person/family/representative per the 14 CRR-NY Part 636-1.3 Person-Centered Planning Requirements. If the person requests a change to their plan the Care Manager must be responsive and work with the person/family/representative to determine if this is something that requires an immediate update or can wait until the next meeting. Ultimately, this is the person’s choice. 

Documentation Informing the Life Plan:

The following documents inform the Life Plan and must be reviewed at least annually or more frequently as needed:

1. Annual Comprehensive Assessment
2. Review Functional Needs Assessment (CAS/CANS):
   • If assessment is not current or a significant change in condition (SCIC) has occurred, request a reassessment at [email protected]
   • If a CAS/CANS reassessment occurs, the Care Manager will need to review the assessment per the outlined process for CAS or CANS and determine with the person and their Care Planning team if any updates to the Life Plan are required. [email protected]
3. DDP2: must be completed at least once every two years or more frequently if the person experiences a significant change in condition.
4. Level of Care Eligibility Determination (LCED): must have redetermination completed within 365 days of previous LCED.
5. NYSDOH Consent Form: review and update to ensure all providers are listed.
6. Annual Rights: which includes person-centered planning process notice, ADA, grievance procedure, and any reasonable accommodation needs.
   • Please note: It is the CCO/HH's responsibility to provide ongoing education to CCO/HH enrollees on their individual rights beyond what is provided at their Life Plan meetings.
7. Other: Review any other documents/plans as applicable to the person based on their services, needs, living situation, etc. such as, but not limited to:
   • Staff Action Plans (SAPs)
   • Behavior Support Plans, including written informed consent and Human Rights Committee (HRC) approval when needed
   • Individual Plan of Protective oversight (IPOP)
   • Plan of Nursing Services (PONS)
   • Personal Expenditure Plan (PEP)
   • Money Management Assessment (MMA)
   • Medication Monitoring Plans (MMP)
   • Individualized Education Plan (IEP)
   • Specialized Clinical Risk Assessment or other specialized assessments
   • Dining guidelines or other plans related to nutrition
   • Agency specific documentation related to emergency situations, time spent alone in the residence, etc.
   • Care Manager Activity Plan (CMAP) required for Willowbrook class members
   • Medical Orders for Life Sustaining Treatment (MOLST) forms
   • Community Inclusion Records
   • Clinic Treatment plan recommendations by Article 16 Clinics as applicable
   • Active Representation for Willowbrook class members
   • Ready to Go Packet (required for Willowbrook class members)
   • Health Care Proxy, Burial Accounts, etc.

Any documentation reviewed as part of the Life Plan meeting must be included as part of the enrollee's electronic health record.

Habilitation providers are often best positioned to know the clinical, medical and health status of those they support and are responsible for communicating that information to the Care Manager and care planning team at the time of the Life Plan meeting.  This will ensure that the most current information regarding the person’s clinical, medical/health, safeguard needs, habilitation needs, etc. are integrated into the Life Plan by the Care Manager. 

It is the responsibility of the habilitation provider to share relevant and pertinent information with the Care Manager prior to, during, and/or after the Life Plan meeting to support development of a comprehensive, person-centered Life Plan by the Care Manager. It is to be established by the care planning team led by the Care Manager in the timeframe in which all needed and/or requested information or documents are to be shared/distributed. If there are other members of the care planning team that should also have this information, this should be discussed, and arrangements for sharing should be made at the time of the Life Plan meeting.

Ensuring that all members of a person’s care planning team have the necessary information to effectively participate in the person-centered planning process and in the development of the enrollee’s Life Plan to support comprehensive care planning is essential to effectively meeting people’s needs. Establishing cooperative and collaborative relationships and agreements between habilitation providers and Care Managers is critical to achieving this outcome. 

All parties are encouraged to work collaboratively and well in advance of the required time-period for Life Plan finalization. If the enrollee, service provider(s), and/or the enrollee’s care planning team disagree about the details of the Life Plan or Staff Action Plan, the Care Manager must work throughout the life planning process to facilitate resolution by implementing the dispute resolution process developed by the CCO/HH as well as the person-centered planning process. Care Managers 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:

At the Life Plan Meeting(s): 

For previously approved services, supports, and goals:

If the disputed element represents a change to a previously approved service, support or goal in a prior finalized 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 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/HH 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 enrollee, their representative, or the provider can initiate a 633.12 objection as outlined below.

Example:

During the person-centered planning process, the enrollee or their advocate requests that additional staffing be included for a pre-existing community inclusion activity but the provider who would be supporting this service asserts that the request is not clinically appropriate. In the event the Care Manager is unable to facilitate a resolution of this dispute, they would leave the prior existing community inclusion goal in the Life Plan unchanged and include a narrative in the “Summary of IDT Meeting” Section regarding the nature of the staffing dispute.

or

For new services, supports, and goals:

If the disputed element represents a new service, support, or goal that was not contained in a previously finalized Life Plan, 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/HH 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 enrollee, their representative, or the provider can initiate a 633.12 objection.

Example: 

During the person-centered planning process, the enrollee or their advocate requests the ability to participate in a certain type of community inclusion activity but the provider who would be supporting that service asserts that the request is not clinically appropriate. In the event the Care Manager is unable to facilitate a resolution of this dispute, the Care Manager would move the community inclusion goal altogether out of the Life Plan and into the “Summary of IDT Meeting” 

Within 45-days of the Life Plan meeting, the Care Manager and the enrollee 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.

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. 

Staff Action Plans are developed and signed by the habilitation staff and forwarded to the Care Manager via the CCO/HH’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 enrollee and their representative and any other parties agreed to by the person and their representative. 

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 enrollee, their representative, or a provider may initiate due process proceedings pursuant to 14 NYCRR 633.12 as an objection to a plan of services. During the pending due process proceeding, all other elements in the finalized Life Plan and Staff Action Plans shall be implemented. Care Managers should inform the enrollee 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.

For more information see Due Process.