DOH Publishes FIDA-Nursing Facility “Frequently Asked Questions”

The Department of Health (DOH) has released answers to frequently asked questions (FAQs) related to nursing facility coverage under the Fully Integrated Duals Advantage (FIDA) program.  The FAQs are available here.

Highlights of the FAQs include:

• 3-Day Hospital Stay: The three-day hospital stay is not required prior to a nursing facility stay under FIDA.
• Continuity of Nursing Facility Care: The FIDA Plan must allow “[p]articipants who reside in a Nursing Facility to maintain [their] current Nursing Facility Provider for the duration of the Demonstration.”
• Pharmacy Coverage and Billing: FIDA plans include Part D coverage. No participant enrolled in a FIDA Plan has a separate Part D Plan. Therefore, all medications that are covered by Part D would be paid for by the FIDA Plan. All plans offering Part D are required to provide “convenient access” to long term care pharmacies for beneficiaries residing in a facility. The nursing home’s contracted pharmacy should submit claims for Part D drugs to the plan (or Pharmacy Benefit Manager if the plan has one).
• Skilled Nursing Need Determination: Decisions regarding the duration of skilled nursing care are made by the FIDA interdisciplinary team (IDT) or FIDA Plan upon receiving a recommendation from the nursing facility.
• Long Term Placement: “The FIDA IDT makes a determination for long term placement based on the plan´s written medical necessity criteria, informed by the clinician´s recommendation, the assessment and person centered care plan. If the determination is outside the scope of practice of the individuals participating in the IDT meeting, the FIDA Plan’s utilization management department may make the decision.”
• Eligibility for Institutional Medicaid: “Like [managed long term care], a FIDA Plan must disenroll a member who is in a [nursing home] and is not eligible for the appropriate [level of] Medicaid eligibility. The FIDA member could be ineligible for institutional Medicaid, but would still be eligible for community-based long term services and can return to the community and receive services covered by the FIDA Plan.”
• Hospice Coverage: When a FIDA participant in a nursing facility elects hospice, hospice expenses are “carved out of the FIDA capitation and reimbursed through [fee-for-service].”

All FIDA materials are available on the DOH website here.

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