February 13, 2014 Managed Care Policy and Planning Meeting

LeadingAge NY participated in the Department of Health (DOH) Feb. 13, 2014 Managed Care Policy and Planning Meeting. For member convenience, we have posted the Department of Health (DOH) documents on our website. To access the documents, please go to the listing below or the “Providers/Managed Long Term Care” page on our website (www.leadingageny.org) and click on the links.

MRT Waiver

Among the highlights of the meeting, DOH announced that they believe they are close to finalizing an agreement with the Centers for Medicare and Medicaid Services (CMS) on the MRT waiver. In fact, later in the day, the Governor announced that the State and CMS have reached an agreement in principle on the waiver that will provide an $8 Billion reinvestment in New York’s health care delivery system.

Overall Enrollment

DOH believes that enrollment across all sectors is going well and the numbers are all trending in the right direction. They intend to further enhance enrollee outreach to minimize the need for auto assignment, and they emphasized that so far auto assignments have been minimal. They also intend to streamline data transfers to eMedNY to effectuate enrollment of new individuals. The intent is for enrollees to be activated in the system as quickly as possible even if on a fee-for-service basis until their managed care status can be implemented. Although there was a slight dip in the mainstream enrollment numbers in December, they believe this is the result of new enrollees waiting for January to enter the New York State of Health Exchange (SoH), and that the number will rebound with the start of SoH coverage in the new year. Along these same lines, in order to ensure a more expedited enrollment process DOH will be putting forth guidance on what they term a “fair” assessment and effectuation process for new enrollees.

Nursing Home Transition

As of this date, DOH anticipates that Mar. 1, 2014 will remain the effective date to begin the transition of nursing home residents into managed care, in line with their recently issued guidance: Office of Health Insurance Programs Transition of Nursing Home Benefit and Population into Managed Care. They indicated that if the date were to move at all, it would be by no more than one month. They acknowledge that there is still a good deal of concern on the part of providers, but stressed that they intend this to be a gradual process. To this end, DOH is planning a March 10 meeting at their offices on Church Street to directly address some of these concerns. This would be a joint meeting with providers and plans. They would then seek to do an upstate meeting along the same lines.

Continuity of Care

Advocates continue to raise concern about the current transition and continuity of care. DOH reports that according to advocacy groups, continuity in services and physician orders is a problem. The current home care provider is in the best position to know the enrollee’s current plan of care and the health plans should be conferring with the home care providers to ensure continuity.

DOH will also be proposing a 10-day notice requirement before plans can terminate coverage, and plans are being asked not to effect a coverage termination on Fridays or just before holidays as this creates a serious challenge for the enrollee to avoid a coverage gap.

Hospice/Specialty Coverage

DOH is reminding plans that hospice room and board is a covered service and must be reimbursed for hospice inpatients. This is factored into the managed care rates and should be included in contracts. They also expressed concern that there are still downstate plans that have not contracted with any nursing homes or specialty institutional providers.

Behavioral Health Payment Methodology

John Gahan of DOH reviewed the current inpatient psychiatric payment methodology as a model for structuring the behavioral health managed care payment system; this presentation is linked below.

Nursing Home Drug Coverage

There is still confusion over the nursing home pharmacy benefit in managed care. It is clear for mainstream coverage that drugs are carved into the rate. For MLTC, however, there is still some confusion. Medicare Part D should be covering dual eligibles, while the non-duals should be billed to Medicaid fee-for-service. DOH is proposing to leave the pharmacy benefit carved out for the first year of the transition and then seek to have it incorporated into the managed care benefit. The plans noted that there are different concerns for short term versus long term residents.

The complete nursing home rate package is due out by the end of April.

New HIV AIDs Therapy

The plans raised concern over a new non-interferon-based medication that appears extremely effective, but is costing the plans upwards of $60,000 per month. DOH acknowledged that this is a problem and will be looking into the possibility of a drug carve out.

Wage Parity

Regarding the ability to raise managed care rates in response to the wage parity requirements, DOH noted that based on Mercer’s actuarial modeling submitted to CMS, they have essentially hit a ceiling in terms of allowable reimbursement (i.e., the rates are 5 percent above the midpoint). The State is proposing to give the plans $30 million by restoring the 2% cut and $20 million through the quality pool. The quality pool funding is exempt from the federal ceiling. This strategy has allowed them to move the wage parity funding in the proposed executive budget from $300 million to $350 million. Any additional rate enhancements would have to be accomplished with state-only dollars, which Jason Helgerson stated was not a viable option. The plans and associations made a strong case for the fact that even with a $350 million enhancement the rates would remain woefully inadequate to cover the cost wage parity.

Regarding the amount to be passed through to LHCSAs, DOH asked for information on rates that plans have negotiated with LHCSAs to cover administrative costs.

ADA Attestations

DOH indicated that it will be providing written guidance on ADA compliance. In essence, it will be requiring plans to identify any provider that is not ADA compliant in the plans’ provider directories, both online and in annual handbooks. The goal is for all providers to be ADA compliant.

FIDA Enrollment

The FIDA Update presentation included a detailed timeline for passive enrollment in FIDA (see link below).

FIDA Three-Way Contract

DOH has asked for a single set of comments from the associations on the 3-way contract.

Plan Access and Availability Compliance

Finally, DOH cited the quality of telephone responses and access as the single most important factor negatively impacting the latest access and availability compliance statistics (see February 13 DOH Access and Availability Presentation below).

For more details on meeting, including many of the statistics and facts presented, please refer to the official DOH presentations listed below:

DOH Presentations:

2014 Managed Care Policy and Planning Meeting Schedule

February 13 DOH Access and Availability Presentation

February 13 Evaluating Health Home Performance

February 13 FIDA Update

February 13 New York State of Health (Exchange) Update

February 13 Patient Centered Medical Home Update

Please contact me with any questions of concerns.

Pat

Patrick Cucinelli, MBA, LNHA, EMT

Senior Director of Public Policy Solutions