MLTC Update: Focus on Fair Hearings
The Department of Health (DOH) held a conference call for managed care plans focused on several key areas, including a delay in the transition of Medicaid enrolled individuals with Substance Use Disorder (SUD) and Mental Health (MH) treatment needs (i.e., the carved out Behavioral Health services) to managed care. This delay is intended to give plans, providers and the state more time to prepare for this transition. The revised implementation timeline is:
- Jan. 1, 2015: BH Adults in NYC (HARP and Non HARP)
- July 1, 2015: BH Adults in Rest of State (HARP and Non- HARP)
- Jan. 1, 2016: BH Children Statewide
For a flowchart with key dates regarding the implementation please click here.
DOH will provide plans with a behavioral health data book on HARP & Non-HARP spend in September, and expects to provide the RFI in October. Plans are advised to review the RFI carefully for issues that may impact their ability to meet HARP & Non-HARP qualifications.
Additional highlights from the call include:
Adult Day Health Care/Aids Adult Day Health Care Update: DOH requested that plans not pend provider claims while awaiting the receipt of requested information to confirm the plan of care. DOH also announced that the state may implement a 90-day deadline from the date of the initial transition of ADHC services for providers to notify plans of all members who are in receipt of services on the date of the transition to managed care.
Fair Hearings: In response to growing concerns raised by consumer advocates, DOH spent considerable time reviewing fair hearing rules and advised plans that they will begin to issue Statements of Deficiency (SODs) for failure to comply with existing statutory and regulatory requirements. DOH focused on the issues of plans sending late or incomplete fair hearing evidence packets and various problems related to the sending of denial notices. In addition to adopting a more aggressive approach to citations, DOH will develop several new tools, including new managed care action taken forms, a new model appeals attachment, new member service survey questions and new operational survey questions. The slide presentation on fair hearings is available by clicking here.
New York City Child Flu Vaccination Program: In response to NYC’s plan for the comprehensive immunization of all children, DOH asked plans to provide feedback on whether it would be easier for them to contract with affiliated physicians for the payment of the administration of flu vaccines or have the reimbursement fall under the local public health unit provisions of the Model Contract.
Hospice Carve-in: The carve-in is scheduled to start Oct. 1, 2013 and will proceed in similar fashion as other long term care carve-ins with a one year transition period (Oct. 31, 2013 – Sept. 30, 2014) during which plans must continue to reimburse vendors at FFS rates. Unlike those transitions, recipients in receipt of hospice on the date of the transition will have benefits continued under FFS. Only members new to hospice on or after the date of the transition would have their benefit provided by the managed care plan. DOH will provide plans with more specific information about rates and hospice billing in the coming weeks. DOH also has an information request from CMS that is due by Sept. 1, and will be asking for plans’ hospice networks in preparation for that submission.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827