Managed Care Policy and Planning Meeting: Latest Update on Jan. 1 NH Transition

The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Dec. 4 in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:

General Information

Jason Helgerson, medicaid director, announced that Valencia Lloyd, director, Division of Managed Care is recuperating from a recent health issue and is expected back at work shortly.

Budget season is fast approaching. The expectation is that DOH will be proposing a budget neutral spending plan that corresponds with the Medicaid global cap amount as set forth in last year’s budget.

The Medicaid program is currently evaluating the potential impact of the President’s recently signed immigration reform measures. DOH anticipates that the impact will be minimal and should not cause a problem with the global cap.

DOH is planning a stakeholder meeting on the Delivery System Reform Incentive Program (DSRIP) to focus on payment reform and avoidable hospital use. Meeting details are to be announced.

The plans raised the issue of the frequency of encounter data reporting. The current process of daily data submissions seems excessive given the fact that reports are not available in real time. In response, DOH will review whether they can move to weekly submissions and will report back to the plans.

Jan. 1 Implementation Dates (including NH transition)

DOH is still confident regarding a Jan. 1, 2015 implementation date for both the Fully Integrated Duals Advantage (FIDA) program and the mandatory enrollment of new nursing home admissions. On the nursing home piece, Mark Kissinger, director, Division of Long Term Care, reported that they are essentially down to a single issue awaiting Centers for Medicare and Medicaid Services (CMS) approval, which he anticipates receiving in the next day or two; therefore, Jan. 1, 2015 remains the nursing home mandatory enrollment transition date.

Likewise, FIDA becomes effective Jan. 1 with Maximus (Medicaid Choice) already having received 19 early FIDA enrollment applications. The weekly FIDA implementation calls are continuing. DOH anticipates starting Contract Management Team (CMT) calls with the plans in the near future.

Maximus issued the first round of FIDA announcement letters, will continue to issue additional letters and will post the enrollment packet on their website. The FIDA plans can begin official marketing efforts as of Dec. 8. The FIDA ombudsman program, Independent Consumer Advocacy Network (ICAN) is slated to become operational in January 2015 and can be reached toll-free at 1-844-614-8800 or online at www.icannys.org.

FIDA Opt Out

In the context of plan concerns over the recently released FIDA rates, DOH stated that they will be announcing the formal process for plans to opt out of FIDA. They confirmed that the opt out window was not triggered by the recent rate release, with the official opt out process and timeframe to be determined.

DISCOs

Plans raised the issue of Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs) implementation and the fact that many of the implementation details are still unclear. DOH acknowledged the need to more fully develop the implementation process and that there may be a need to reevaluate the current timelines, possibly seeking some delay in the process.

BH/HARP

The Behavioral Health/Harp application process for upstate is currently projected to start in January 2015.

For plans participating in the behavioral health program, DOH released the billing codes, but is not assigning pricing to the codes. The actual payment rates remain subject to negotiation.

Pharmacy Stop Loss

Plans asked about any adjustments the pharmacy stop loss. DOH anticipates that the amount of the stop loss will be increased and reflected in the April rate adjustments. DOH is also in the process of re-evaluating the data in order to incorporate the most accurate and timely cost factors.

Provider Training

DOH reminded plans regarding recent guidance issued on mandatory provider training. The Lewin Group has to finalize and post the training modules. DOH acknowledges that the Jan. 1 deadline for certain elements of the provider training to be completed is not practical and they anticipate that this date will have to be moved.

Additional Provider Training Workgroup Updates:

CMS and DOH provided comments to the stakeholder workgroup on submitted training materials. The workgroup had until Dec. 8 to submit the final training;
Lewin will post the final training on its web portal;
the workgroup will continue drafting the other required training modules such as ADA and cultural competency modules;
DOH and CMS released guidance on which providers must complete each of the training requirements; and
in November, DOH provided outreach and education to New York City’s Human Resources Administration (HRA) and the Mental Health Association in New York State (MHANYS).

Department of Labor Home Care Worker Wage Changes

DOH is in the process of developing guidance on the recent Department of Labor guidance on overtime and live-in coverage for home care workers. They also anticipate freeing up some Balancing Incentives Program dollars, approximately $5 million, to assist in funding the additional costs.

Integrating Health Homes and MLTC

Plans raised concerns regarding the need for additional guidance on the integration of health homes and Managed Long Term Care (MLTC). Currently, health homes are not in the MLTC benefit package and the relationship between the two benefits is unclear. DOH still needs to figure out how to coordinate the two and assess the need for additional contract language. DOH also plans to release guidance on joint health home and MLTC care planning standards.

Conflict Free Evaluation and Enrollment Center (CFEEC)

DOH offered an initial analysis of the CFEEC. With the phase-in having begun in October, the CFE is now operational in Manhattan, Bronx, Kings, Queens, Nassau and Richmond. The next implementation step is slated for February 2015 and will include Westchester and Suffolk counties. Maximus is experiencing an average call volume of approximately 245 per day. (Please see FIDA Update slides for more details and statistics.) Maximus currently has 48 nurses on staff, and they have been able to increase by nine, the number of Spanish speaking nurses. DOH confirmed that Maximus is completing assessments on Saturdays.

DOH is currently in the process of obtaining more detailed reports from Maximus. Early indications are that 96 percent of CFEEC referrals are approved for Medicaid, with 73 percent enrolling with the plan with which they made initial contact or the plan that initiated the referral. Most of the denials are related to individuals that are seeking only social day or personal care services. DOH is also looking to streamline the call center script in order to increase efficiency. Maximus will also be notifying plans of their enrollment referral statistics by the second week of each month.

Plans raised concern that assessments are not being completed within the required five to seven days. This in turn creates problems for timely enrollments, especially if the delay crosses over the 20^th of the month, thus creating a potential six week delay in enrollment. DOH noted the concern and asked that plans provide them with actionable details to assist in resolving any issues. The plans are in turn asking Maximus to identify any impediments to enrollment that they are encountering.

FIDA Update (please see slides for additional details)

DOH continues its weekly FIDA Plan Implementation calls on Fridays. The mailing of the Program Announcement letters to all potentially eligible FIDA participants in Region I (New York City and Nassau) began on Dec. 1, 2014, and will continue on a rolling basis this week and next. Sample announcement letters were sent to plans, advocates, the Human Resources Administration (HRA) and Nassau County Department of Social Services. Additional FIDA updates included:

the Final State Specific Enrollment Guidance will be released this week;
the Ombudsman program, known as the Independent Consumer Advocacy Network (ICAN), began on Dec. 1, 2014 in FIDA Region I (see above); and
the FIDA Encounter Data Workgroup met on Nov. 25, 2014, to finalize the FIDA procedure and specialty codes and review questions. An Encounter Data Q&A document was released to all FIDA Plans.

CMS has opened the door for additional counties to transition to mandatory managed care enrollment for individuals requiring home and community based services (HCBS) for 120 days of more. CMS approved the mandatory managed long term care (MLTC) transition in Chenango, Cortland, Livingston, Ontario, Steuben, Tioga, Tompkins and Wayne counties. The counties slated for Dec. transition include: Genesee, Orleans, Otsego, and Wyoming, pending network approval by CMS.

Mainstream and MLTC Rates (please see slides for additional details)

DOH and Mercer (actuary contractor for managed care rate setting) noted their intent to finalize MLTC rates, locking down the rates for April and July 2014. The plans noted a problem with rate uncertainty and finalizing their financial statements and reporting. The plans asked if DOH could provide some notice of rate clarification that would satisfy auditors pending final CMS approval. DOH noted that they are cautious about doing so given potential liability. DOH agreed to review draft language submitted by the plans that may satisfy auditing standards for revenue recognition. DOH also suggested that plans have the option of reaching out directly to CMS regarding the delays in rate approvals.

As noted above, the plans raised concern about the adequacy of FIDA rates and managed care rates in general, in addition to the uncertainty regarding the final CMS rate approvals. One issue is the assumption of a 90:10 ratio of Nursing Home Certifiable (NHC) to Non-nursing Home Certifiable (NNHC) when actual claims data shows a ratio of 98:2. Mercer noted that the figures were adjusted from an original 80:20 ratio in response to the assessment data. The projection is that eventually the ratio will settle out close to the 90:10.

There was also a discussion of the incremental increase in the managed care efficiency adjustment from 20.4 percent to 23.71 percent. DOH noted that they are slowly ratcheting up the figure based on a projected 34 percent efficiency increase (the FIDA-specific projection is 28 percent). Mercer noted that there is room for additional savings and efficiency across the board.

In response to the level of plan concern over rate issues, DOH agreed to schedule a dedicated meeting with Mercer to address these concerns.

In an additional discussion on FIDA rates, DOH noted that the nursing home adjustments and risk adjustments would not be reflected until the April 1, 2015 rates and depend upon additional agreement from CMS. DOH reiterated that the current FIDA rates are the final community rates, but they do not trigger to the 10 day opt out clock. As noted above, the process for the opt out is yet to be resolved.

Additional details for Mainstream Plans:

Inpatient adjustment brought initial Mercer inpatient trend assumptions down to reflect current costs based on final 7/1/14 Inpatient Fee Schedule.
Pharmacy Premium Enhancement – $32M will be added to the rate effective July 1. This will be in addition to the $75M already in the July package.
Non-Qualifying Quality Incentive (QI) Plans – Additional funds will be available for those plans that have made improvements, but still do not qualify for the MMC QI. In order to qualify, plans must develop a plan to engage in payment reform (DOH estimates this amount at around $10 million) and these funds will focus on:
- Exploring Value Based Payment arrangements (e.g. upside/downside risk, global payments, sub-capitation, etc.); and
- controlling high utilization/high volume services.

For MLTC rates, DOH noted the following key assumptions:

no changes in 2014 mandatory rates and 2015 FIDA rates;
implement the change to the Medicare Savings adjustment to exclude Part D effective in 2014 PACE premium rates;
no 2012 Risk Corridor Settlement and no recoupment of the $3.4M from Plans;
commit to an additional $10M of new money in 2015 MLTC rates to support administrative costs related to NH transition; and
DOH will pursue establishing a fund pool in FIDA to support implementing shared savings (this would be new money).

Hepatitis C Drug Coverage

DOH stated that they are still pursuing pricing contracts for Sovaldi. The attorney general is also investigating the manufacturer’s overall pricing policy. There is a second drug entering the market, and DOH is looking at how this will impact the overall cost of Hepatitis C drug therapy.

DSRIP

The first phase of network development in DSRIP ends Dec. 8. DOH is seeking comments from plans on the structure of the networks, in anticipation of a second phase in which the Performing Provider Systems (PPSs) may add managed care organizations as plan partners. Statewide, there are 25 PPSs. Requests for capital restructuring are due by Feb. 22, 2014. DOH is also seeking regulatory relief recommendations due Dec. 22.

Managed Care and HIV SNPs Efficiency Adjustment

DOH reviewed this collaborative effort to develop efficiency and quality metrics that include prevention, quality indicators, pediatric-specific quality indicators and measures of preventable emergency room visits. DOH will work with 3M and Mercer to develop these quality metrics into plan specific adjustments for mainstream and HIV Special Needs Plans (SNPs). Also included will be potentially preventable ancillary services. Please see the linked slide presentation for more details.

Integrated License Pilot Program

DOH acknowledges that this is a small and limited demonstration program, but they believe it is still a very important project. The project allows for an agency that currently operates programs under two different licenses to coordinate billing and reimbursement under a single set of billing codes and reimbursement (using APGs). Reimbursement will include a 5 percent rate enhancement on a site specific basis. The project is slated to operate for a very limited period of time starting in 2015.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827