Frequently Asked Questions on the Single Fiscal Intermediary

As part of the state’s budget this past year, Gov. Hochul and the Legislature determined that all of CDPAP will be administered by one fiscal intermediary (FI). Governor Hochul and her Department of Health chose Public Partnerships, LLC, or PPL, as the sole FI for the state. This means that, if this measure takes effect, consumers and their personal assistants will have to switch from their current FI to enroll with PPL in order to continue to use CDPA. CDPAANYS will keep you up to date with information about when you have to make this change.

Right now, fiscal intermediaries (FIs) are continuing to operate as normal. However, unless the law is changed, your fiscal intermediary will be required to close by April 1, 2025. If you want to continue to use your FI until that date, you do not need to do anything unless and until you are told by the Department of Health, your managed care company or county, or see it through CDPAANYS.

You do not need to change your FI today. Your current fiscal intermediary is allowed to continue operating until April 1, 2025. You will receive mailers from the Department of Health, Public Partnerships, LLC (PPL), and/or your managed care plan telling you to switch. There are positives and negatives to switching early, as well as switching at the last minute. It is up to you to decide if you would like to wait.

Governor Hochul and her Department of Health chose Public Partnerships, LLC, or PPL, as the state’s single fiscal intermediary. The Georgia-based company has a history of having worked in NJ, WA, PA, CO, and a number of other states, although many of those contracts no longer are in place.

The law passed by Governor Hochul and the Legislature required that the company chosen to be the single statewide FI must have experience running an FI  statewide in any other state besides New York. This meant that most FIs in New York were not qualified to apply. The few agencies who were qualified were unsuccessful, although because the law eliminated many standard contracting rules, we do not know why.

At CDPAANYS, we are unclear as to how Governor Hochul arrived at $500 million in estimated savings from this policy change. The Division of the Budget, in charge of the state’s finances, did not make their estimates public. Through Medicaid rate reductions to managed care plans, DOH has already enacted $700 in cuts to CDPA this year. Those savings will disappear when the switch to PPL is made, as the agency’s reimbursement was determined by their contract. This means that to achieve the $500 million in additional savings, the state will in fact need to save $1.2 billion overall. DOH also plans to reduce CDPAP eligibility in the coming months based on disability, claiming too many consumers are enrolled.

While some states like Pennsylvania and Washington State do use only one FI, Governor Hochul’s comments about California were incorrect. California uses a network of public authorities to administer their self-directed program. Each county in the state has a public authority created for the sole purpose of administering that county’s self-directed benefit. That means while there is one FI per county, there are many FIs that can account for the different needs of each local county.

Before Pennsylvania transitioned to one FI, its self-directed program had 36 FIs and 20,000 consumers. Today advocates in Pennsylvania tell us there are 8,000. PPLs electronic visit verification (EVV) system did not recognize several consumers, which prevented them from accessing their services. EVV problems also kept workers from receiving paychecks for up to 6 – 8 weeks. A class action lawsuit is still pending due to a failure to pay overtime hours While PPL still has a contract in Pennsylvania, it is only for a fraction of the state’s participants in fee-for-service Medicaid. The strong majority of consumers who self-direct through managed long term care do so with Tempus, a different company.

When Governor Hochul and the Legislature changed the law to create a single statewide fiscal intermediary (FI), they also created “subcontractors.” The first group of subcontractors announced by the state were called “core lead agencies.” Our understanding, based on conversations with a number of agencies, is that the role of core lead agencies will not differ from that of other subcontractors. These subcontractors are current FIs who, while they will no longer be a FI, will be allowed to continue to operate in some form or fashion. It is not known what these agencies will do as no agency actually has a contract as a subcontractor yet; however, they are legally prevented from performing key FI functions such as setting wages or benefits; processing payroll; contracting with managed care plans or counties; or determining the electronic visit verification (EVV) system that will be used.

When Governor Hochul and the Legislature changed the law to create a single statewide fiscal intermediary (FI), they also created “subcontractors.” In November, Governor Hochul announced 24 agencies that are currently acting as FIs that would be able to partner with PPL as subcontractors. These are in addition to the four entities that were named as “core lead agencies” in the original announcement of an award to PPL. Our understanding is that there will not be a difference between core lead agencies and subcontractors. In fact, in recent presentations, PPL has referred to all of the potential partners (nobody has a signed contract yet) as “facilitators.” Whether the agency is a facilitator, a subcontractor, or a core lead agency, they are legally prevented from performing most responsibilities that are core functions of an FI, such as setting wages; contracting with managed care plans or counties; or determining the electronic visit verification (EVV) system.

Because the law passed by Governor Hochul and the Legislature only allows the single statewide fiscal intermediary (FI), or PPL, to perform core functions of a FI, every consumer will have to transition themselves and their personal assistants to PPL, even if your current fiscal intermediary is a core regional home care partner or other subcontractor.

 If the state makes this switch, your current fiscal intermediary (FI) will no longer be your FI, even if it is an ILC. When Governor Hochul and the Legislature changed the law to create a single statewide fiscal intermediary, they also created “subcontractors.” The law names ILCs as a special group of agencies entitled to a role as a “subcontractor.” The law states that subcontractors cannot set wages or benefits; processing payroll; contract with managed care plans or counties; or decide which electronic visit verification (EVV) system that will be used.You may still interact with your ILC FI in some way but it will be different from your current relationship. We do not yet know what this will look like.

The law passed by Governor Hochul and the Legislature that requires a single statewide FI also required subcontractors. While the initial set of subcontractors, dubbed the “core regional agencies” filled the requirements of the law, the Governor expanded the list of subcontractors to include 24 additional agencies currently operating as FIs who will help PPL perform various roles such as onboarding and interacting with consumers. These subcontractors are not different in any way from the four core regional agencies. Their role is limited and they are not allowed to contract with managed care plans or counties, set and process payroll and benefits, or choose their EVV system. Details about what these additional subcontractors duties will be are yet to be announced and we will update accordingly once that information is shared.

Though you will not have to go through the eligibility and enrollment process again, you will still need to switch to a new fiscal intermediary (FI). Whenever a consumer changes their FI, the consumer and their personal assistant (PA) must go through the onboarding process, which includes health assessments and other steps for PAs before they can begin work. Nearly half a million PAs will be transferring by April 1, 2025, which will lead to annual health assessments being due at nearly the same time for all PAs, rather than spread throughout the year as they currently are. This is very likely to create significant delays in both initial onboarding and annual assessments, causing service disruptions for consumers.

No requirement was added to the law that would mandate, or permit, a criminal background check for personal assistants (PAs) unless it is requested by the consumer. The program’s rules, including those in the request for proposals that Public Partnerships, LLC, or PPL, submitted to become the state’s single fiscal intermediary (FI), is clear that the consumer and/or the consumer’s designated representative have sole authority over who is hired. An explicit statement authorizing PPL, or any FI, to exclude a PA based on a criminal background check, would therefore be needed to allow such exclusions. CDPAANYS will work to educate decision-makers about the harm any proposal that seeks to limit who can be a PA based on criminal background checks or other measures not currently in law would cause and its impact on the “Dignity of Risk” model that serves as the foundation of CDPA.

No.  While switching from CDPA to “traditional” personal care services may be better for some, there are four critical differences that you should know. First, while personal assistants (PAs) in CDPAP can do personal care, home health care, and nursing services, personal care attendants (PCAs) in “traditional” personal care can only do personal care tasks. This means no medication administration, wound care, suctioning, or other more intensive tasks. Second, your PA will now only work for the agency. That means the agency can schedule them to work for other people, and potentially not for you at all, and you will not control the schedule. Third, PCAs in “traditional” personal care may not be family members, so if your family is your PA, they will not be permitted to do so in a “traditional” agency setting. Fourth, while PAs do not need formal training or credentialing, staff in “traditional” agencies do. If you are considering changing, talk to the FI/LHCSA about all of these factors before deciding which is best for you.

 All three of these jobs are broadly referred to as “home care workers” but there are important differences between them that shape the way consumers receive services:

• CDPAP is self-directing and allows the consumer or their designated representative (DR) to hire a person of their choosing to serve as their personal assistant, or PA. The consumer or DR is responsible for hiring, training, and if necessary firing a PA. The only people who cannot work as a PA are the consumer’s DR, legal spouse, or parents of a consumer under 21 years of age. The PA may reside with the consumer and do personal care (housekeeping, dressing, bathing), home health care (wound care), and nursing (suctioning, medication administration) tasks. 
  
  
• A personal care aide, or PCA is an individual who has taken a training course, is licensed through the state, and works for a licensed home care agency. They are limited in some tasks they can perform (housekeeping, meal preparation, dressing, bathing, transferring) and are assigned by their employer agency to patients on a schedule set by the agency. A PCA cannot be a spouse, parent, son, son-in-law, daughter or daughter-in-law, or any family member who resides in the same household.
  
  
• A home health aide, or HHA, can do more than a PCA but less than a nurse. A HHA will often do more complex tasks such as wound care or meal preparation for diabetics or others with restricted diets. Like a PCA, a HHA is assigned by their employer agency, in this case a Certified Home Health Agency or CHHA, to patients on a schedule set by the agency. A HHA cannot be a spouse, parent, son, son-in-law, daughter or daughter-in-law, or any family member who resides in the same household.

Wages and benefits will be set by PPL. While we do not know what the wage will be, it is anticipated that it will be the Home Care Minimum Wage, currently $18.55 in New York City, Westchester, and Long Island, and $17.55 in the rest of the state. PAs working for consumers in New York City, Long Island, and Westchester will still receive have to receive additional wages and benefits that bring their total compensation to a “wage parity” level; however, it is unlikely these benefits will be paid in wages as many FIs currently do. In the remainder of the counties we do not anticipate any benefits for PAs. 

The Department of Health reduced Medicaid managed care payments to FIs on August 1, 2024, with an average cut of 4% across the state. Due to these reduced payments, many FIs were forced to reduce PA pay and benefits, limited or eliminated overtime, and ended paid time off. 

CDPAANYS sued the state on the grounds that DOH did not follow proper procedure when it adopted the Medicaid cuts and are expecting a decision before the end of 2024. CDPAANYS sued on similar grounds in 2019 – and won – due to the state’s failure to follow the State Administrative Procedures Act (SAPA) when it implemented a per-member, per-month (PMPM) reimbursement formula. As a result, the finalized rates were significantly higher than what was initially announced. We hope to repeat this success and at least restore FI rates to what they were prior to August 1.