Managed Care Policy and Planning Meeting
The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Oct. 8th in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:
- October 2015 Mercer Rate Analysis
- October 2015 Patient Centered Medical Home Update
- October 2015 MLTC and FIDA Update
- October 2015 Supplemental Nutrition Women, Infants, and Children's Program
- October 2015 Health Homes Administrative Services Agreements
- October 2015 Behavioral Health Billing Issues
- October 2015 Behavioral Health Policy Guidance
- October 2015 Children's Health and Behavioral Health Design Update
General Information
Valencia Lloyd, director, Office of Health Insurance Programs (OHIP), started the meeting with a discussion of the Behavioral Health (BH) transition that started as of Oct. 1st. Her office is seeking input from plans on the progress of the transition, in order to ensure a smooth process and the timely payment of claims. She noted that there was an issue with transportation claims brought to the attention of OHIP and the agency was able to act quickly to resolve the problem.
Greg Allen, director, OHIP Division of Financial Planning and Policy, noted that certifying the servicing provider‘s licensure on the claims is not required and they are developing a process to work around the current edit.
Mr. Allen also reminded the Managed Long Term Care Plans (MLTCs) of the requirement to be certified with the Medicaid All Payer Database (APD). The APD is a central clearinghouse for Medicaid claims data and will provide detailed information on Medicaid expenditures for a variety of stakeholders. All plans were due to be certified by Sept. 14th, but DOH reports that some plans are still not certified. The priority is to ensure that pharmacy encounter data is able to be submitted during the month of October in order to ensure that pharmacy rebates are obtained.
DOH provided a brief Delivery System Reform Incentive Payment (DSRIP) program update focused on the data sharing initiative. There will be two phases of mailings to Medicaid enrollees (Phase 1 October/November 2015 – 700,000 letters and Phase 2 February/March 2016 over 5 million letters) explaining their options under the data sharing Opt-out option. The letters provide an overview of DSRIP, an explanation of their rights under the data sharing program, and the benefits of data sharing. Essentially, all Medicaid enrollees will be included in the DSRIP data sharing process unless they choose to opt-out. In addition, the State’s 25 Performing Provider Systems (PPSs) and the managed care organizations (MCOs) may send out their own communications.
DOH views this as a new concept in data sharing, and they are hoping that PPSs and MCOs will be actively sharing information necessary to coordinate the enrollee’s care and improve quality. Maximus (NY Medicaid Choice) will coordinate the Opt-out process and will use the client identification number to coordinate data. DOH advised plans to be sure their Health Commerce System (HCS) contact information is accurate as they will be updating files through the HCS.
Negotiations are currently underway for the PPS network contracting and funds flow models, as detailed in the Quarterly Reports. Areas of negotiations include: Value Based Payment (VBP) contracting; Equity Payments; Regulatory issues and model contracts; and Data Sharing. Regarding the issue of funds flow, DOH stated that they are not mandating any specific models, allowing the PPSs considerable latitude in their program designs. However, DOH noted that non-safety net providers are eligible to receive, in aggregate, DSRIP payments totaling no more than 5 percent. The PPSs will also have the ability to expand upon their initial plans in subsequent Quarterly Reports as their projects continue to evolve.
The plans noted that there is still considerable confusion over the issue of DSRIP funds flow. Mr. Allen suggested that a “master diagram” of the funds flow process may help provide clarity and DOH will develop such a document.
The PPS Program Advisory and Oversight Panel (PAOP) will be reviewing progress reports from 11 upstate PPSs on Nov. 9th and 10th, and 14 downstate PPS progress reports sometime in January 2016. An initial DOH review indicated that the reports lacked the specificity necessary to ensure the PPS is on the right “path to success.” With subsequent improvements, DOH now feels that all the PPSs are on a “green for go” status.
DOH pointed out the examples of two notable PPS projects:
- An initiative in Staten Island that seeks to develop a complete database of all health care providers in the geographic area; and
- A project in the Finger Lakes to correlate efforts to reduce poverty with health improvement.
Regarding the VBP Roadmap, DOH noted:
- The draft Medicare Alignment paper with stakeholder feedback is due to CMS for approval;
- The revised alignment document will be posted to the DSRIP website; and
- VBP subcommittees (technical design, Social Determinants, Regulatory and Clinical Advisory Committees) are actively working.
Jason Helgerson, director, NYS Medicaid, discussed a vision for an evolving role for MCOs. He advised that they are seeking greater engagement between the PPSs and the MCOs, with a need to improve connections. There is a need to redefine the role of the MCOs in a DSRIP environment, especially with the move towards VBP. It is clear that the plans will be taking on an increasingly important role. Health Information Technology (HIT) and more comprehensive data are critical elements in improving connectivity between the PPS and the MCO. The plans may also play a role in improving coordination between providers. For example, can enhanced coordination play a role in reducing the degree to which substance abuse is a driver of unnecessary hospitalizations.
The PPS are currently gearing up to receive claims data. Claims data dashboards are expected to go live in January, using a high level of data and excluding any Protected Health Information (PHI).
The analysis from Mercer, the DOH actuary, provides updates on the following Oct. 1, 2016 rate adjustments:
- Transgender Benefit
- Pharmacy Adjustments
- Behavioral Health Add-on
- Health and Recovery Plan (HARP) Population Adjustment
- Risk Adjustment
- Aliessa – Mainstream and Essential Plan
Patient Centered Medical Home Update
On Jan. 1, 2016, DOH will update the reimbursement for the Patient Centered Medical Home (PCMH) incentive payments to reflect the program changes that were originally published in the February 2015 Medicaid Update. Incentives for providers recognized at level 2 or level 3 under National Committee for Quality Assurance’s (NCQA) 2011 standards will be reduced and incentives for providers recognized at level 2 or level 3 under NCQA’s 2014 standards will be increased. The linked DOH update contains details on the incentives and resources to contact with further questions.
DOH reported that as of Oct. 1, 2015 the Fully Integrated Duals Advantage (FIDA) enrollment numbers were as follows:
FIDA Enrollment Update – Oct. 1, 2015
- 9,065 Total Current Enrollment
- 2,887 Passive Enrollments on Oct. 1, 2015
- 2,777 IDT Meetings Completed
You may compare these numbers with last month’s statistics:
FIDA Enrollment Update – Sept. 1, 2015
FIDA Enrollment NY Medicaid Choice Calls Received Total Opt-Outs
7,280 96,976 57,375
DOH issued a revised Interdisciplinary Team (IDT) Policy Sept. 15, 2015, available by clicking here. DOH indicated that additional changes to the FIDA program may be forthcoming based on the issues discussed at the Sept. 29th LTC Forum. 530 stakeholders participated in person or by telephone and the white paper and slides are available by clicking here. DOH continues to solicit additional comments. Slide 6 of the DOH presentation provides details on recent changes to the provider training requirements, and DOH and the Centers for Medicare and Medicaid Services (CMS) may consider additional revisions.
The Managed Long Term Care (MLTC) enrollment numbers reported for October showed an increase in the number of total enrollees statewide from 147,588 reported last month to 150,202 enrollees. The numbers break down as follows:
- Partially Capitated (MLTC) 130,280
- Medicaid Advantage Plus (MAP) 6,140
- FIDA 7,280
- Program of All-Inclusive Care for the Elderly (PACE) 5,502
The corresponding numbers for September were:
-Partially Capitated (MLTC) 128,298
- Medicaid Advantage Plus (MAP) 6,098
- FIDA 7,676
- Program of All-Inclusive Care for the Elderly (PACE) 5,516
Mandatory Medicaid enrollment is now in effect statewide, with a total of 66 plans comprised of 18 FIDA, 8 MAP, 8 PACE and 32 single cap MLTCs representing the bulk of enrollments. These numbers are unchanged from September.
Since the last Policy and Planning meeting, DOH reports that a survey is being conducted to ascertain compliance with MLTC Policy 14.08: Paying for Live-In 24 Hour Care for Personal Care Services and Consumer Directed Personal Assistance Services. DOH held a Nursing Home Transition and Diversion (NHTD) and Traumatic Brain Injury (TBI) waiver transition to managed care subcommittee meeting on Oct. 6, 2015.
Supplemental Nutrition Women, Infants, and Children's Program
DOH provided an information session on the Supplemental Nutrition Women, Infants, and Children's Program (WIC), which can be used to supplement and support the managed care plan benefit package. DOH specifically noted that the support services accessed under WIC do not overlap with managed care benefits and, again, may be fully utilized to augment the standard benefit package.
Health Homes Administrative Services Agreements
DOH reports that MCOs have entered into Administrative Services Agreements (ASAs) with one or more Health Homes to provide Health Home care management services to enrollees. Under an ASA, DOH notes the following options:
- Using the DOH standard template, as is with no changes;
- Using the DOH standard template with modifications; or
- Using DOH Key Provisions to develop a customized contract.
Accordingly, DOH has made revisions to the standard template and Key Provisions that will need to be reflected in any ASAs.
Revisions to the ASA template have been shared with Health Homes, MCOs, and plan associations and the comments received have been incorporated in the revisions. The new language includes:
- Incorporation of language to allow MCOs to share data with Care Management Agencies;
- Elimination of the 3% administrative withhold by MCOs from the Health Home PMPM;
- Reference to the need for Health Homes to conduct State-required assessments; and
- Edits and revisions for clarity around the terms for contract termination.
DOH is developing guidance on submitting revised contracts. Please see the linked slide presentation for more details.
Behavioral Health
The following presentations from DOH provide important updates on the transition of BH services to managed care:
- Behavioral Health Billing Issues
- Behavioral Health Policy Guidance
- Children's Health and Behavioral Health Design Update
The billing issues relate to three areas: 1.) Denial of supporting submission and payment of claims using the Office of Alcohol and Substance Abuse Services (OASAS) or Office of Mental Health (OMH) unlicensed practitioner ID; 2.) Supporting submission and payment of claims for programs still completing the contract process; and 3.) Claim requirements of practitioner reporting for ACT and PROS programs. The DOH update includes specific guidance on each of these issues.
OMH and OASAS, in collaboration with DOH have developed their policy guidance on the transition of the full Medicaid behavioral health system to managed care. Their goal is to create a fully integrated behavioral health (mental health and Substance Use Disorder) and physical health service system that provides comprehensive, accessible, and recovery oriented services. There are three components of the transition: 1.) Expansion of covered behavioral health services in Medicaid Managed Care; 2.) Elimination of the exclusion for Social Security Income (SSI); and 3.) Implementation of HARP. The referenced policy guidance is an important resource for plans and providers to use to direct and managed the transition process.
As outlined in the guidance on Children’s Health and BH Design, the transition includes the following phases:
- Phase I: Enrollment of Children into Health Home (January 2016);
- Phase II: Implementation of six new State Plan services (July 2016);
- Phase III: Transition of existing BH Medicaid services, six new State Plan services, new array of HCBS benefits and foster care population to MMC (NYC + LI January 2017, ROS July 2017);
- Phase IV: Discontinuance of five children‘s 1915c Waivers (late 2017); and
- Phase V: Expansion of target population to include children meeting Level of Need criteria (January/July 2018).
Please be sure to review the slide presentation for more details.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827.