September Managed Care Policy and Planning Meeting
The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Sept. 11 in Albany. Highlights of the meeting are presented below and include an announcement that the transition to managed care for nursing home residents in downstate areas is delayed until January 2015, and that Fidelis Care is the first managed care plan to have received authorization to serve every county in the State. For member convenience, all of the reference materials from the meeting have been posted to the LeadingAge NY website; click on the links below to access the documents.
September 2014 MMC and FHP HARP Transition Pop Adj Impacts
September 2014 Mainstream Rates Status and Timeline
September 2014 FIDA and MLTC Update
September 2014 Children’s MMC Update
September 2014 FY 2014-15 MMC January Rates
September 2014 FY15 MMC FHP HIVSNP Pharmacy Update
September 2014 MLTC Rates Update
September 2014 Adult Behavioral Health Transition
DSRIP Update
Medicaid director Jason Helgerson opened the discussion with a Delivery System Reform Incentive Payment (DSRIP) update. DOH is working to make information on proposed PPS provider networks available and will generate an initial attribution list. A draft application scoring tool is being developed and should be done by the end of the month. DOH has two vendors working on DSRIP issues: KPMG with 60 dedicated staff members and PCG, an assessor that is working on the application scoring tool.
The State is considering reconvening the Medicaid Global Cap work group to help formulate a master plan for steering the State’s managed care programs in a direction that is consistent with DSRIP. The goal is to have a plan to submit to the Centers fro Medicare and Medicaid Services (CMS) by April 2015 with draft documents available for public comment in January or February.
The State expects that PPS networks will be locked down by mid to late November, around the time that applications are due. Detailed work plans would be the first main deliverable that DSRIP PPSs would need to provide and first DSRIP payments would be made in April 2015. The State is seeking suggestions and input from plans as they start to gather ideas on developing workforce training programs for which $245 million has been designated. The State is also finalizing the State plan amendment regarding $500 million in Health Home funding with the hope that CMS approval is provided quickly since the discussion parallels previous waiver negotiations the State and CMS have had.
In response to questions regarding antitrust concerns stemming from DSRIP networks, DOH stressed that the Certificates of Public Advantage (COPAs) that would be granted would include specific conditions and limitations and be monitored closely to make sure that organizations remain within reasonable boundaries. DOH and their contractors are investigating value-based payment models and seeking examples wherever they can be found. DOH is aware that some health plans already have pioneered value based payment approaches and DOH will be reaching out to those plans for their input. A survey is planned at the end of the year to collect information on what plans are already doing to better gauge what changes in regulations or legislation may be required.
Nursing Home Transition Update
Although CMS has not yet issued formal Special Terms and Conditions for the transition of the nursing home population and benefit into managed care, discussions between the State and CMS have identified several specific issues that need to be addressed. These issues include implementation of conflict free assessment prior to the rollout, as well as an independent consumer support (ombudsman) program for which the State has already entered into contract. The State must also implement a procedure for educating beneficiaries regarding managed care plan selection. On the rate setting side, CMS is requiring that transition rates be phased out by April 2016 and that the State use an integrated blended rate in Managed Long Term Care (MLTC) and mainstream Medicaid Managed Care (MMC) for both community-based and nursing home services. Jason Helgerson stressed that the ultimate goal of the State is to go to a single Medicaid managed care rate structure.
Home Based Services Data Request
In response to litigation regarding long-term services and supports, the State is making a home-based services data request of all MLTC and mainstream MMC plans. A new spreadsheet requesting specific data will be distributed and will be due on Oct.10, 2014. It will collect data covering the period from Jan. 1, 2013 through June 30, 2014, broken down by quarter. Plans will need to submit data on the number of enrollees receiving home care, personal care, consumer-directed program services and private duty nursing. Along with the number of enrollees receiving these services, plans will need to report the number of enrollees experiencing service reductions and terminations, as well as the number requesting service increases that are denied. This is expected to be a one-time survey.
DOH is also implementing intensive monitoring of aid continuing and will require plans to contact DOH by e-mail when an appeal concerning one of the four Long Term Services and Supports (LTSS) is received starting Sept. 22, 2014. Mainstream plans will also be required to attest that they are meeting the requirements regarding long-term services and supports that are in their contract provisions.
FIDA and MLTC Update
Fully Integrated Dual Advantage (FIDA) contracts are expected to be fully executed in October and CMS and DOH expect to issue final readiness reports in November. The next FIDA plan meeting is on Sept. 23 in New York City and will focus on marketing. Remaining handbook chapters will be released on a rolling basis. Phase 2 enrollment notices are being updated based on comments received and the State is focusing on developing a process to streamline training requirements. DOH is establishing a work group with plans and advocates to determine training materials and is trying to learn from other States where provider education has been found to be key. DOH is seeking ideas to reach physicians specifically. A standard clauses document has been developed that can be attached to provider contracts to take into account the differences between MLTC and FIDA without rewriting the contract. On the MLTC transition front, mandatory managed care for those requiring 120 days or more of community-based care has begun in Dutchess, Montgomery, Broome, Fulton and Schoharie counties. DOH updated the transition timeline on their website.
Conflict Free Assessment
To meet the requirements of the State's special terms and conditions for mandatory managed care, the State will implement a Conflict Free Evaluation and Enrollment Center (CFEEC) for Medicaid enrollees needing community-based long-term care services for more than 120 days. This will begin in October 2014. Maximus, the current enrollment broker for New York's Medicaid managed care program, will perform the evaluations including scheduling initial assessments and providing the nurse evaluators to assess the potential enrollees in the home, hospital or nursing home. This will be required for new consumers seeking MLTC services. Enrollment into a plan will not be allowed until Maximus has conducted the initial evaluation and determined that the individual is eligible for community-based long-term care. MLTC plans will be responsible for completing their own assessments for care planning purposes, but will have access to the assessment performed by Maximus. The process is not intended for individuals transferring from one plan to another nor is it required for nursing home residents enrolled in a MLTCP returning to the community.
Although there was some concern expressed that Maximus staff may not be fully familiar with all plan types and services, the State stressed that Maximus would assist and provide information on all of the options. DOH put together a discrete adjudication process for those cases where the CFEEC determination may differ from the MLTC eligibility determination. That process will involve submitting a disagreement request to Maximus for clinical staff review with the possibility of escalation to the state for final determination. The CFEEC would be rolled out in Manhattan and Bronx in October; Kings, Queens, Nassau and Richmond in November; Westchester and Suffolk County in February 2015; and Hudson Valley, the Capital Region and Erie, Monroe and Onondaga in March 2015. Southern Tier, Finger Lakes and Western NY regions will follow in April 2015, with Central and Northern parts of the State being phased in in May 2015. The State is planning a webinar for plans and providers towards the end of September and will compile and disseminate FAQs.
Rate Update
DOH continues to work towards issuing a series of MLTC rates summarized in the table below. The State and Mercer are evaluating the impact of the UAS and intend to schedule a call with plans to establish a transition process. DOH is pursuing potential premium increases in upstate areas using BIP and Network Incentive Payments and is developing a summary of Methods document for calculating risk scores for mandatory populations. In response to a question, DOH confirmed that a list of enrollees who count as mandatory members is available if plans reach out to the Department.
|
Effective Date |
Rate Description |
Release Date |
|
CY 2012 |
Risk Corridor |
9/26/2014 |
|
4/1/2014 |
Mandatory – Statewide to implemented by county transition timeline |
9/19/2014 |
|
CMS Approved Date |
Nursing Home Duals |
CMS Approved Date |
|
1/1/12; 1/1/13; 1/1/14 |
MA, MAP Rates (3 yrs) |
9/30/2014 |
|
4/1/2014 |
QIVAPP Pool Payments |
October 2014 |
|
4/1/2014 |
QI, High Cost High Need Pool Payments |
January 2015 |
|
SFY 2013-14 |
HR&R Awards - MLTC, PACE, MAP |
Janaury 2015 |
|
4/1/2015 |
Risk Adjusted Rates |
March 2015 |
|
Mainstream Rate Package |
Comment/Projected Completion |
|
January 2014 (ACA) |
CMS Questions (Round 4) / 9/15/2014 |
|
Aliessa (4/1/13; 7/1/13; 1/1/14) |
Package with DOB/CMS |
|
April 2014 Rates |
Package with DOB/CMS |
|
Cost Weight Update |
9/25/2014 Conference Call |
|
ACA Tax Bill |
September 2014 |
|
July Rate Update |
October 2014 |
Pharmacy Update
DOH reported on the pharmacy encounter data analysis performed by the State and Mercer that was aimed at comparing health plan and Fee-for-Service (FFS) pricing, analyzing clinical edits and projecting costs for Hepatitis C drugs. Although there were some regional variation, drug costs tended to be slightly lower in the FFS environment than in managed care in the 4th quarter of 2013 and 1st quarter of 2014.
In screening encounter data for therapy duplication, quantity limits and age and gender restrictions Mercer identified approximately $29.3 million in “inefficient” spending in the New York City area and $26.6 million in the rest of the State. The HIV SNP figure was $8.6 million. DOH promised to share this data with plans on a plan-specific basis and said that the findings were likely to impact pharmacy rates for the coming year.
Based on an analysis of health plan Hepatitis C drug expenses and assuming potential savings from an Oct. 1, 2014 implementation of Uniform Prior Authorization criteria, the State intends to increase drug reimbursement rates by $75 million from July 2014 through March 2015. Based on input provided by meeting participants DOH will review the prior authorization savings estimates. Pharmacy reports will be shared with plans via pharmacy dashboards.
Other Updates
OPWDD has a multi-year path to transition the current FFS system to managed care beginning Oct., 2015 when individuals with developmental disabilities will have the choice to voluntarily enroll into Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs). The DRAFT DISCO Contract and other application materials are available for informational purposes on the DISCO website. An applicant teleconference was held Sept. 12 and questions and answers on the application will be posted in late September. Applications are due Nov. 1, 2014.
In preparation for the transition of adult behavioral health services to managed care, the State is organizing a series of kick-off forums aimed at connecting plan representatives with providers. A listing of events is available here. Several forums are scheduled for late September in New York City and early October in Albany.
Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841