Managed Care Policy and Planning Meeting

The Department of Health (DOH) hosted its monthly Managed Care Policy and Planning Meeting on May 15 in Albany.  For member convenience, we have posted all of the reference materials from the meeting as on our website as follows:

Final Agenda

June 2014 Model Contract Revisions Program Integrity

June 2014 Health and Recovery Program Rate Development – Rest of State

June 2014 Health and Recovery Program Rates Sheets – Rest of State

June 2014 FIDA Update

June 2014 Reducing Unintended Pregnancies

June 2014 Children’s Medicaid Managed Care Update

June 2014 Identifying Inappropriate PCI Cases

June 2014 Managed Care Pharmacy Benefit Initiatives

General Discussion

The opening discussion focused on transition issues.  The Department of Health (DOH) acknowledged ongoing concerns from hospice providers.  DOH believes that this reflects the need for additional outreach and training for these providers and plans.  In particular, there is confusion over the managed care hospice benefit for nursing home residents.   In this regard, DOH has been meeting with hospice providers and plans concerning additional education on how the benefit works under managed care, in addition to direct outreach to specific providers.  The group agreed that medical directors and medical management staff need to be part of this outreach.  Back payments should be available to providers who need to re-submit claims once any confusion regarding the managed care hospice benefit is clarified. 

The Centers for Medicare and Medicaid Services (CMS) has not yet approved the transition of new, permanent nursing home resident to  mandatory managed care enrollment  DOH has responded to the latest round of CMS questions.  However, it remains unclear as to whether the planned July 1  transition date Downstate (Jan. 1, 2015 for rest of State)for new-to-service nursing home admissions will hold.  The date may have to be pushed back even further. 

There was further discussion on the nursing home transition later in the meeting.  For Downstate, we are currently looking at a July 1 nursing home transition date with Jan. 1, 2015 Fully Integrated Duals Advantage (FIDA) passive enrollment for dual eligible beneficiaries receiving long-term care services (eight FIDA region counties only).  Should DOH need to push the July 1 date even further back, they raised the possibility of transitioning the Downstate nursing home population directly from fee-for-service (FFS) to FIDA, thus eliminating the interim managed care transition for new admissions.  This is only in the initial discussion phase at this time, and the impact on the transition for new admits in the rest of the State is unclear.

Upcoming calls for plans: June 18 - Medicaid Child Health Insurance Program, and June 24 - Regularly Scheduled Call on Health Exchange.

Model Contract Revisions Program Integrity - The Office of Medicaid Inspector General (OMIG) and the Attorney General’s Medicaid Fraud Control Unit (MCFU) did a presentation on revisions to the managed care model contract program integrity provisions.  They emphasized the current compliance program requirement that any provider receiving $500,000 or more in Medicaid funds per year (regardless of whether they are FFS or managed care payments)  adopt and implement a compliance program and  submit an annual attestation.

They then reviewed the duty of managed care plans to monitor their contractors for potential fraud and misconduct, with a special emphasis on pharmacy providers.  The reporting standard requiring the managed care organization (MCO) to report fraud and abuse has changed from a “confirmed” to “reasonably suspected” (see slide 13).  OMIG and MCFU see the MCOs as partners in monitoring the activity of both Medicaid participating and non-participating providers, and looking for data trends that would indicate inappropriate billing.  In this regard the MCO must take reasonable steps to ensure that data collected from all providers is accurate and complete.

Both MCFU and OMIG expressed concern over the low volume of referrals from plans.  They also noted that this seems to be a national trend and that the federal government is starting to look at the issue.  The two agencies want New York to be ahead of the rest of the country and view the MCO compliance reports as the key element in this process. 

Slide 6 of the presentation gives the revised schedule and standards for MCOs to submit encounter data, increasing the frequency from monthly to every two weeks.  The MCO is also required to submit pharmacy data in Medicaid Encounter Data (MEDS) format on a daily basis.  The attendees raised serious concerns about this requirement as there is often a lag between when a prescription is filled and when it is actually received by the beneficiary; it is not unusual that a week could go by between the two occurrences.  “No-fills” were cited as a problem by both agencies, and they cited Savoldi™ claims as a growing concern.  The plans responded that due to the lag time, they have no control over when and if a beneficiary actually picks up their medication. 

Again, much of the focus of this discussion related to pharmacy issues, and plans expressed frustration that they do not necessarily have the real time data available to meet OMIG/MCFU expectations for their oversight of the pharmacy benefit.  OMIG/MCFU acknowledged the need to take this information back and re-examine their expectations.

It is important for plans to review the linked slide presentation for more specific details in terms of wording changes to the model contract.

HEP C Medications – The plans reported on their meeting to discuss Savoldi™ and the new class of Hepatitis C medications.  They reported that their group recommendations are going to DOH the week of June 16, and the report includes clinical and financial recommendations on how best to manage and administer the new drugs from the plan perspective. 

Aliessa – As reported in the May meeting, DOH is still seeking to transition all Aliessa (i.e., lawfully-present immigrants with an immigration status that renders them ineligible for federal financial participation) beneficiaries into Basic Health plans.  Mainstream plans currently enrolling Aliessa beneficiaries are reminded to submit all medical data by July 24, 2014.

The Aliessa rates are still awaiting CMS approval.  In the meantime mainstream plans should continue to bill current (April 2013) rates using current codes.  This means that it remains important for the plans to be identifying their Aliessa claims, until such time as the federal rate codes are available.

June 2014 Health and Recovery Program Rate Development – Rest of State – DOH and Mercer representatives presented on the current status of the Health and Recovery Program (HARP) rates for the non-FIDA regions of the State.   The New York City rates were discussed during the May meeting.   The basic premium rates were developed based on the historical experience in the “Data Book”, along with additional adjustments.  At this time, health homes are excluded from the rates as DOH finalizes the arrangements for payments and conditions with the federal government.  Among the program change adjustments is the inclusion of the pharmacy benefit.   It is important to note that the base data include inputs from both the FFS and managed care sides.  Included in the presentation was the following: Health and Recovery Program Rates Sheets – Rest of State.

DOH also confirmed that it is not necessary for a HARP plan to join a health home.  They noted that it certainly makes sense to do so, but is not a requirement.  All told they anticipate between 118,000 to 140,000 HARP enrollees.

June 2014 FIDA Update – FIDA rates (not including nursing home rates) are slated to be released on June 16.  A teleconference or webinar on the rates is being planned with CMS likely to be presenting on the Medicare side of the equation.  On June 17, DOH will be discussing a proposal on the nursing home FIDA rates with CMS; key to the nursing home discussion will be operationalizing the net applied monthly income piece.  Issues raised by the nursing home associations will also be reviewed.  Once this review occurs, CMS is expected to make quick decisions on the nursing home rates.   Please also note the above discussion on whether there may be a direct transition from FFS into FIDA, without the interim managed care enrollment, for nursing home residents.

Additional highlights of the FIDA update:

The final IDT Policy was issued on 6/5/14. This Policy will be in effect for Demonstration Year 1;

• The remaining desk deficiencies related to the IDT were also issued and Plans had to submit responses;
• DOH and CMS met with Plans in NYC on 5/29/14 to discuss the enrollment process; and
• The next meeting is scheduled for 6/23/14 in NYC. At this meeting they plan to discuss the draft enrollment guidance, enrollment scenarios, Maximus file formats, as well as distribute an enrollment FAQ.

Regarding the three-way contracts:

The draft contract was shared with plans, providers, and advocates on April 28^th;

• Plans, providers and advocates submitted priority comments and conferences calls were held to discuss the comments received;
• DOH/CMS will send a revised contract to plans for their signature on or about June 16; and
• Plans must return signed contracts by July 7th.

June 2014 Reducing Unintended Pregnancies – The NYC DOH presented data on the effectiveness of providing immediate post-partum and post-abortion contraception as a means of reducing unintended pregnancies.  The analysis cites both the health benefits to the woman and the cost-effectiveness of the procedures.  Post-partum contraception is a new FFS benefit that is estimated to save upwards of $400,000 for every 1,000 women annually.  The comparable cost savings on the post-abortion side is $450,000 for every 1,000 women annually.

June 2014 Children’s Medicaid Managed Care Update – This presentation emphasized the unique aspects of structuring a managed care program for children, especially when it comes to behavioral health issues.  They cited the following major themes in behavioral health interventions for children:

Intervening early in the progression of behavioral health disorders is effective and reduces cost;

• Accountability for outcomes across all payers is needed for children’s behavioral health;
• Solutions should address unique needs of children in a unified, integrated approach;
• The current behavioral healthcare system for children and their families is underfunded; and
• Children in other public or private health plans should have access to a reasonable range of behavioral health benefits.

June 2014 Identifying Inappropriate PCI Cases – This presentation detailed how DOH will implement the new appropriate use criteria for percutaneous coronary interventions, generally referred to as cardiac cauterizations.  Based upon criteria developed by the American College of Cardiac Surgeons and other professional groups, the process would look at 5 patient characteristics to determine the appropriateness of the PCI: 

• Clinical presentation
• Severity of angina
• Extent of ischemia on noninvasive testing
• Extent of medical therapy
• Extent of anatomic disease 

The review would result in findings that the procedure was: 1.) Appropriate, 2.) Uncertain, or3.) Inappropriate.  A finding of inappropriate can be appealed and additional factors submitted for consideration.  The rationale is based on an assumption that to a certain extent the PCI procedures are over utilized and that in many cases other less intensive interventions would have been sufficient.  The hope is that this will result in a reduction in unnecessary PCIs. 

June 2014 Managed Care Pharmacy Benefit Initiatives – This presentation focused on the implementation of the following initiatives from the recently passed State budget: 

• Prior Authorization for Non-Medically Accepted Indications; and
• Aligning statewide Drug Utilization Review (DUR) programs by expanding point of sale clinical pharmacy editing in MCOs. 

In both of these initiatives DOH is seeking to leverage point of sale clinical editing or automated prior authorizations.  The rationale is that enhanced clinical editing can reduce costs and improve patient care for the entire Medicaid program by:

• Decreasing administrative functions (fax transmission, phone calls and time-consuming expensive manual clinical reviews);  and
• Decreasing inappropriate use and enforcing clinically appropriate use of medications by incorporating data from pharmacy claims, medical claims, eligibility systems and call centers. 

The Medicaid Drug Utilization Review Board will be providing critical support in implementing both of these initiatives. 

For more details on the meeting, please refer to the DOH references linked above. 

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