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Managed Care Policy and Planning Meeting

The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on August 13 in Albany.  For member convenience, we have posted all of the reference materials from the meeting on our website as follows:

-          August 2015 Agenda

-          August 2015 FIDA MLTC Update

-          August 2015 Rates and Value Based Payment Guidance

-          August 2015 Medical Home Payment Guidance

-          August 2015 Behavioral Health Transition

-          August 2015 Behavioral Health Information Sheet

-          August 2015 Schedule of HARP Notice Releases

Additionally, in connection with the Health and Recovery Plan (HARP) notice release schedule listed above, DOH included a series of notices and letters that are linked as follows for your convenience:

-          August 2015 HARP Information Notice

-          August 2015 HARP Passive Enrollment Information

-          August 2015 HARP Voluntary Enrollment Letter

-          August 2015 HARP Voluntary Notice

-          August 2015 HARP Concurrent Plan Notice

FIDA MLTC Update

DOH reported that as of Aug. 1, 2015 the Fully Integrated Duals Advantage (FIDA) enrollment numbers were as follows:

FIDA Enrollment Update – Aug. 1, 2015

FIDA Enrollment                               NY Medicaid Choice Calls Received                          Total Opt-Outs

       7,676                                                              96,976                                                           54,287

You may compare these numbers with last month’s statistics:

FIDA Enrollment Update – July 1, 2015

FIDA Enrollment                               NY Medicaid Choice Calls Received                          Total Opt-Outs

       6,368                                                           88,705                                                              51,328

DOH is projecting the following FIDA passive enrollment schedule:

August 1:

-          2,701 individuals were passively enrolled

September 1:

-          60 day letter was sent June 23, 2015

-          30 day letter was sent July 23, 2015

-          1,379 individuals are set to be passively enrolled

October 1:

-          60 day was sent July 30 - August 4, 2015

-          30 day will be sent August 24 - 27, 2015

-          7,500 individuals are set to be passively enrolled

DOH reminded plans that the deadline for the FIDA value based contracting proposals (i.e., alternative payment proposals) has been pushed back to Jan. 1, 2016.

Other updates since the July meeting include:

-          Calendar Year 2016 marketing materials have been released except for the provider directory;

-          Plans can expect that an interim directory will released shortly;

-          The annual marketing plan is due Aug. 31st;

-          DOH issued a mandatory welcome packet insert that plans must utilize; and

-          The Year 2 credentialing requirement will be rescinded.

The Managed Long Term Care (MLTC) enrollment numbers reported for July showed a slight increase in the number of total enrollees statewide from 143,963 reported last month to 146,154 enrollees.   This number breaks downs according to the following plans:

-         Partially Capitated (MLTC)    128,765

-         Medicaid Advantage Plus (MAP)     6,148

-         FIDA    6,368

-         Program of All-Inclusive Care for the Elderly (PACE)     5,473

Mandatory Medicaid enrollment is now in effect statewide, with a total of 69 plans comprised of 21 FIDA, 8 MAP, 8 PACE and 32 single cap MLTCs representing the bulk of enrollments as noted above.

DOH emphasized the importance of GIS 15 MA/011: Reminder of Expedited Authorization Process for Medicaid Recipients with Immediate Need for Personal Care Services.  This policy, which is effective immediately, reminds local departments of social services of long-standing Department regulations that provide for an expedited authorization process for Medicaid recipients (i.e. persons who have been determined to be financially and otherwise eligible for Medicaid) who need personal care services immediately to protect their health or safety but the nursing assessment cannot be completed in five business days.

DOH also released guidance materials related to the elimination of internal appeal exhaustion requirements and the new model action notices for Partial Capitation Plans along with the posting of MLTC Policy 15.04: Interim Guidance for MLTC Partial Capitation Appeal Notices.

The Conflict Free Evaluation and Enrollment Center (CFEEC) is now operational statewide.  DOH reported that the approval rate for individuals referred to the CFEEC, which is run by Maximus, remains high at 97 percent, with 32,317 evaluations completed.  DOH noted that the referral rate in some upstate counties remains low and they are evaluating the situation.

The Rates and Value Based Payment Guidance provides the latest rate schedules for both Mainstream and MLTC plans.   In addition, DOH includes a detailed description of the Value Based Payment:  Quality Improvement Program (VBP QIP).   Under this program, funds have been allocated to support the transition of certain financially challenged providers to VBP, as an alternative to the State-administered Vital Access Provider Assistance Program (VAPAP).   After September of this year, these two programs will be mutually exclusive, with the goal of having most providers participating in the managed care organizations (MCOs) administered VBP QIP program, along with a separate allocation for the Health and Hospitals Corporation (HHC) VBP.  DOH is allocating a total of $320 million with $200 million set aside for non-HHC providers.  The VBP QIP program will require close coordination between the MCOs and the Performing Provider Systems (PPSs) under Delivery System Reform Incentive Program (DSRIP).

Medical Home Payment Guidance

Payments under the Patient Centered Medical Home program (PCMH and Adirondack Medical Home) have been removed from the premium effective April 1, 2015 per directive from the Centers for Medicare and Medicaid Services (CMS).  MCOs will be paid two times per year based on medical home expenses reported in the Q2 and Annual MMCORs/HIV SNPORs.  The first payment will be based on the Q2 2015 MMCOR/HIV SNPOR and will include a reconciliation to determine if the plan has been overpaid or underpaid through March 31, 2015. The reconciliation will be netted from the first payment.   If a plan owes money the State will use this balance and net it against future medical home expenses.   The reconciliation for all plans will be based on payments to plans included in the rates through March 31, 2015 and medical home expenses incurred through June 30, 2015 (reported in the Q2 2015 MMCOR/HIV SNPOR.)

Behavioral Health Transition

DOH provided extensive guidance on the Behavioral Health (BH) and HARP transitions.  Members should refer to the materials linked above for more details.  The Behavioral Health Information Sheet provides an excellent information resource and the Schedule of HARP Notice Releases is also an excellent reference tool.

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