DSRIP Weekly Update-June 30, 2015

The Department of Health (DOH) issued an update this past week regarding DSRIP activities. Performing Provider Systems (PPSs) have submitted implementation Plans for Domain 1; these plans are currently under review. DOH has provided baseline data and additional attribution information to the PPSs. DOH also reported that there was a PPS meeting in NYC on June 18, 2015. DOH has developed a table of key deliverables, with links to a variety of resources including documents from the PPS meeting. Click here to access the table.

Below are some of the highlights of the key activities:

Funds Flow

DOH provided a webinar on “Funds Flow”, which can be accessed here. The PPS lead, which must be a Safety Net provider, has to develop a clear plan regarding the funding distribution to partners which complies with federal fraud and abuse requirements. The plan must address a variety of issues including:

project implementation costs;
costs for delivery of services not reimbursed or under-reimbursed by Medicaid;
provider performance payments;
compensate revenue loss; and,
administrative and other costs not included in previous categories.

It is important to note that PPS funds are subject to recoupment if it is determined that funds are willfully misused and/or information relied upon for payment purposes was misreported or falsely stated. OMIG will be providing some additional updated guidance on these issues.

Of importance to members is the provision that 95% of DSRIP funding needs to be paid out to Safety Net providers. Once payments are received from the PPS lead, however, partners are not restricted from making payments to other in-network or out-of-network providers. For more details, see the aforementioned webinar and slides.

Consumer Opt-Out Letters

An“opt-out letter” will be sent to consumers to provide the opportunity to chose NOT to have their protected health information (PHI) and Medicaid data shared with the PPS to which they have been attributed, an approach that mirros the Medicare Accountable Care Organization (ACO) model. The consumer will "participate' in the sharing of PHI-level unless he/she affirmatively opts-out. This should not be confused with the opt-out process that also exists for the Fully Intergated Duals Advantatge (FIDA) managed care enrollment, a distinct and unrelated consumer opt-out.

The State cannot share any PHI with the PPS partners until the process is complete, likely in Dec. of 2015. Data regarding consumers that opt-out will not be included in the data provided to PPS leads and their partners. PPSs already have some access to data regarding their members, with information redacted. Consumers can opt-out by filling out and returning the form provided in the outreach letter, or calling the Medicaid Call Center (staffed by Maximus) at 1-855-329-8850. Consumer are given 30 days to opt-out in the mailing sent. That being said, consumers can opt-out at any time, but if already "participating", it could take up to 60 days to affect data distribution. Over 6 million letters are going out this summer to Medicaid members. We anticipate that consumers served by our members may pose questions; they should be directed to the Medcaid Call Center phone number listed above.

Contact: Diane Darbyshire, ddarbyshire@leadingageny.org, 518-867-8828

Eventually, the opt-out process will transition to the Medicaid enrollment process.