Social Services - Medical Assistance - Health Home Care Management Plan - Disenrollment - Failure to Provide Valid Consent Form or Individualized Service Plan

Determination of respondent New York State Department of Health, dated November 7, 2023, which, after a hearing, affirmed a determination to discontinue petitioner's enrollment in a case management service plan, unanimously confirmed, the petition denied, and the proceeding brought pursuant to CPLR article 78 (transferred to this Court by order, Supreme Court, New York County [Lynn R. Kotler, J.], entered Aug. 8, 2024), dismissed, without costs.

Petitioner, an adult qualifying for medical assistance through Medicaid, participated in New York State's Home and Community-Based Services (HCBS) through respondent Office for People with Developmental Disabilities (OPWDD), and was enrolled in a Health Home Care Management Plan, a comprehensive case management service. Health Home Care Management was administered by Care Design, a private nonprofit organization that serves as a Care Coordination Organization (CCO) designated by OPWDD. Petitioner sought to switch from the more comprehensive Health Home plan to a Basic HCBS plan. Although OPWDD gave petitioner a consent form for a basic HCBS plan, he struck out multiple provisions in the form before signing it, and his form was therefore flagged by Care Design's compliance department as invalid. As a result, OPWDD did not enroll petitioner in a Basic HCBS plan, and he remained enrolled in a Health Home plan.

In 2020, petitioner and his assigned care manager were unable to agree on an individualized service plan (ISP), which was required by both the Basic HCBS plan and the Health Home plan. By notice of disenrollment dated January 12, 2021, Care Design notified petitioner of its intent to disenroll him from Health Home services effective February 12, 2021, because of his failure to provide Care Design with a valid consent form or a valid ISP.

Because petitioner failed to submit either a valid consent form or a complete ISP, Care Design's determination to discontinue petitioner's Health Home services was supported by substantial evidence (see CPLR 7803 [4]; 300 Gramatan Ave. Assoc. v State Div. of Human Rights, 45 NY2d 176, 181-182 [1978]; Matter of Shuman v New York State Racing & Wagering Bd., 40 AD3d 385, 385 [1st Dept 2007]). The notice of disenrollment was timely and provided petitioner with adequate notice, as it was provided at least 10 days before the disenrollment. The notice also set forth specific reasons for disenrollment, as well as the regulation upon which the action was based (18 NYCRR 358-2.2 [a] [3], [4]).

We have considered petitioner's remaining arguments and find them unavailing. Concur—Moulton, J.P., Scarpulla, Rosado, O'Neill Levy, Chan, JJ.