DOH Details Managed Care Budget Proposals in Meeting with Plans

The Department of Health’s (DOH’s) January 21^st Managed Care Policy and Planning Meeting focused on the Executive Budget proposals targeted at Medicaid managed care plans. The following key proposals would impact managed long term care (MLTC) plans and other long-term, managed care products:

MLTC Transportation Carve-Out: This proposal would eliminate transportation from the MLTC benefit package and delegate transportation to the State's transportation management contractor.
Additional MLTC Benefits: This proposal would add out-patient mental health benefits, respite, and other services to the MLTC benefit package. This appears to relate to the MLTC Plus proposal floated in late 2015.
Managed Care Profit Limit: This proposal would limit Medicaid managed care plan profits by imposing an 89.5 percent minimum loss ratio. It would apply to MLTC plans.
Limiting MLTC to Beneficiaries Requiring Nursing Home Level of Care (NHLOC): According to DOH, 99 percent of MLTC beneficiaries are currently NHLOC-eligible. The $3.8 million ($11.2 million full annual) savings projected from this change in MLTC eligibility was based on the difference between the capitated rate and fee-for-service spending for beneficiaries requiring 120 days or more of community-based long-term care.
Encounter Data Penalties: The penalties for late, incomplete or erroneous encounter data would apply to MLTC and related plans, as well as mainstream plans.
Actuary Contract Costs: Under this proposal, all Medicaid managed care plans would be assessed to cover the cost of the State’s contract with its actuary, Mercer.
OMIG Fiscal Integrity Program: This proposal would establish a fraud recovery target for each Medicaid managed care plan based on a percentage of its revenue which would be deducted from the rate on an upfront basis. If plans recover more than their target, they would be allowed to retain the additional amount.

In addition to the budget presentation, the Department and the plans discussed the following:

Fair Hearings: Plan representatives raised concerns about the fair hearing process. The Department indicated that it is tracking fair hearing decisions and encouraged plans to provide examples of decisions that plans believe were incorrectly decided.
QIVAPP: IPRO has completed its validation work, and the State is now reviewing the report, which identified significant changes in provider eligibility.
Fair Labor Standards Act Funding: The Division of Budget (DOB) has approved the 34 cent per hour add on to October 1, 2015 MMC and MLTC rates. The State’s actuary is in the process of surveying MLTC plans to determine the impact for April 1, 2016 rates.
Value Based Payment Baseline Survey: DOH will hold a webinar with plans to review the VBP baseline survey which will be used to measure plans movement to VBP in accordance with the requirements of the DSRIP waiver terms and conditions
MLTC:
- Mandatory enrollment in MLTC is up to 155,656 members as of the December enrollment reports, fueled by new all-time highs in the partial cap program with 137,705 enrollees, an increase of 2,858 from Nov.
- Since the last meeting, DOH has posted new policies on the Conflict-Free Evaluation and Enrollment Center Dispute Resolution (MLTC Policy 15.08) and Changes to the Regulations for PCS and CDPA (15.09).
- The nursing home resident survey showed a significantly higher enrollment of nursing home residents than expected. These figures will be incorporated into the Phase 3 rates.
FIDA: DOH extended the deadline for FIDA plans to submit information about their Alternative Payment Arrangements to April 1, 2016. DOH and CMS are hosting a FIDA educational event for providers and plans on Jan. 27th that will highlight best practices and experiences. Despite efforts to sustain and modify the program, enrollment continues to fall. FIDA lost 1,320 members between Nov. and Dec. and now has 6,220 members. The FIDA implementation conference call will be held every other week.

Immediately after the Policy and Planning meeting, managed care plans met with the Department of Health and advocates for providers and beneficiaries participating in the Traumatic Brain Injury (TBI) waiver and the Nursing Home Transition and Diversion (NHTD) waiver to discuss the mandatory enrollment of these beneficiaries into managed care plans. The two groups of waiver beneficiaries are scheduled to transition into managed care on Jan. 1, 2017, with coverage to commence on Apr. 1, 2017. Approximately 6,000 beneficiaries currently receive services through these two waivers; more than half are dually-eligible for Medicare and Medicaid. A significant portion of the NHTD Waiver participants have dementia.

Currently, the Department is planning to require managed care plans to contract for two years with any waiver provider that serves five or more participants and to continue to pay those providers at their waiver rates for four waiver services:

Independent Living Skills Training
Positive Behavioral Intervention and Support
Community Integration Services
Structured Day Services.

These services will be made available only to waiver participants and plan members who would have been eligible for the TBI or NHTD waiver, if the waivers had remained in effect.

The role of the waivers’ Regional Resource Development Centers (RRDCs) in the context of a managed care program is a major outstanding question. The Department is considering retaining the RRDCs to recommend services to the plans and conduct care coordination.

Key hand-outs from the meeting are available here and here.

Contact: Karen Lipson, klipson@leadingageny.org, 518-867-8383, ext. 124.