Managed Care Policy and Planning Meeting
The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on July 17 in Albany. For member convenience, we have posted all of the reference materials, courtesy of Hinman Straub, from the meeting on our website as follows:
July 2014 MLTC Rate Update and NH Transition Timeline
July 2014 Behavioral Health and HARP Managed Care Update
July 2014 Implementing Behavioral Health Managed Care
General Information
Jason Helgerson opened the meeting by discussing the potential of two serious labor disputes that could impact the delivery of home and community-based services, including the Long Island Railroad and SEIU 1199 Home Care Workers. Please note that in both cases a strike has since been averted.
As a follow-up to the June Managed Care Policy and Planning Meeting presentation by the Office of Medicaid Inspector General (OMIG) and the Attorney General Medicaid Fraud Control Unit (MFCU), there have been additional discussions with the federal Centers for Medicare and Medicaid Services (CMS) regarding the structuring of audit and recovery systems. The Department of Health (DOH) understands that issues around pharmacy reporting may be problematic, especially as it concerns the daily reporting of pharmacy claims. Further discussions with the plans and CMS will be undertaken in advance of the Jan. 1 deadline. In the interest of meeting the CMS submission deadline, however, the most recent contract amendments to CMS include language specifying the daily reporting, but DOH believes that there is opportunity to make changes if needed.
Valencia Lloyd reviewed a recent call with the plans to encourage them to continue retroactive enrollments. There is still concern with duplicate enrollments and payments where the individual has selected a plan but there is a delay or error in picking them up in the system. DOH estimates that there have been between 8 and 9 thousand retroactive enrollments over the past few months, not all of them in managed care. There are concerns with both ensuring that enrollees have the right coverage and that payments are not duplicated between the fee-for-service and managed care programs. There have been approximately 200 duplicate enrollments statewide. DOH will be making the determination as to the appropriate placement. Nondiscretionary retroactive enrollments will continue for three classes: Newborns; Instances where there has been a system error; and Temporary loss of coverage.
For the second year in a row, New York Medicaid anticipates an audit from the federal Office of Inspector General. This is not considered unusual given the emphasis on compliance and auditing from the federal government. DOH is asking all plans to be prepared for the audit, with a focus on ensuring that all credentialing and referrals are up to date. While most of the focus in prior audits has been on managed care, DOH expects that managed long term care will also come under increased scrutiny in the future. A subset of plans has been randomly selected and will be reviewed; initial letters indicate that those plans will be Fidelis, Health First, Metro Plus and CDPHP. DOH will be issuing an advisory with a general update and notice on program integrity.
The issue of a stop loss proposal for high cost drugs, Sovaldi – Hepatitis C-type drugs in particular, remains under consideration as recent discussions with the plans continue. There remains serious concern with both the current stop loss proposal and the adequacy of plan pharmacy premiums in general.
July 2014 MLTC Rate Update and NH Transition Timeline: DOH provided an updated timeline for Managed Long Term Care Rates and the nursing home transition. The main discussion was focused on the nursing home transition to managed long term care. Jason Helgerson indicated that the current transition date of Aug. 1, 2014 will likely be postponed once again as negotiations with CMS continue. Any operational questions on the nursing home transition should be referred to Mark Kissinger or Valencia Lloyd. The DOH Nursing Home Transition Policy Paper needs to be updated to reflect new guidance on the Personal Needs Allowance, Conflict Free Case Management (CFCM) and Veterans Administration Services. CMS may also condition the approval of the State’s nursing home transition plan on the successful implementation of CFCM, which DOH does not anticipate happening until October. DOH intends to publish FIDA rates per the current schedule, regardless of the timing of the CMS approval of the nursing home transition plan. The FIDA rates will include a blend of the MLTC rates both before and including the nursing home transition.
July 2014 Behavioral Health and HARP Managed Care Update: DOH believes that there has been good progress on developing a stop loss rate for Health and Recovery Plans (HARPs). The stop loss rates will incorporate factors for substance abuse and rehabilitation. DOH anticipates being able to release the rates in time for plans to determine whether or not to participate in HARP.
An additional stop loss for HIV Special Needs Plans and HARPs takes effect on Jan.1, 2015 and will be on a per episode basis with incremental increases of 45 days in the first year, 60 days in the second and 100 days in year three, according to the chart on page 5 of the slides.
Page 7 of the slides presents the HARP NYC risk corridors for administrative, start-up and pay-for-performance cost. DOH defines these costs according to the following guidelines using the categories from the chart on page 7:
- “Compromise” columns reflect NYC percentages relevant to the Risk Corridor/MLR calculation (not premiums). No additional funds will be added to the premium: Percentages will need to be recalculated once additional services are brought into the premium (e.g. 1915i, Health Home, etc.);
- Any administrative and Start-Up expenditures greater than the allowances reflected in the “Compromise” columns above will first be an offset to the profit/underwriting gain reserve. In any year if the sum of a HARP's expenditures for administration, Start-up, and profit/underwriting gain exceed the amounts above, the HARP shall repay the difference to NYS. The HARP will have the option of directly repaying the total amount due or having the payment withheld from monthly premiums paid the HARP at a rate 5 percent of the premiums due the HARP until the amount is repaid; The Year 3 proposal, which currently focuses on P4P to produce income to plans, will remain a tentative proposal. The State is open to exploring the elimination of Risk Corridor/MLR in Year 3 and identify resources to enhance P4P; and
- The chart does not take into consideration how the Risk Corridor/MLR on the Mainstream BHO “carve in” or HIV/SNP HARP will be calculated.
July 2014 DISCO Update: The Office for Persons with Developmental Disabilities (OPWDD) provided an update on the Developmental Disabilities Individual Support and Care Coordination Organizations (DISCOs). The rolling application process will start in August of 2014 with no set deadline for final applications. However, initial start-up grants are subject to certain time limits and may be unavailable past a certain date. MLTC plans may be eligible to serve as DISCOs in limited circumstances where there is not another plan available in the geographic region.
DOH presented the following important dates regarding DISCO implementation:
- 8/1/14 - Draft Plan Qualification Document for DISCO/COA approval.
- 9/1/14 - Proxy DISCO rates posted for grant application fiscals.
- 10/1/14 - If applying for start-up funds, Sections of COA application due.
- 10/15/14 - Funding approval/ contracts begin.
- 11/14 - OPWDD/FIDA rates final and released.
- 4/1/15 - OPWDD/FIDA enrollment begins.
- 10/1/15 - DISCO enrollment begins.
July 2014 FIDA Update: DOH reviewed the revised FIDA implementation schedule, which is now slated to begin Jan. 1, 2015 for New York City and Nassau County and April 1, 2015 for Suffolk and Westchester Counties. Mandatory enrollment will begin April 1, 2015 for New York City and Nassau County and July 1, 2015 for Suffolk and Westchester. The DOH slides contain an extensive timeline of important dates and deliverables for plans to reference. Additional enrollment guidance is due out in August.
The plans specifically requested that DOH provide additional guidance and materials regarding marketing policies and practices. The plans expressed serious concern during the meeting over the need to have clear guidance in this area and DOH agreed. DOH emphasized the following points regarding the marketing initiatives:
- 30-day marketing activities will begin December 2014;
- All marketing materials (required templates and other discretionary materials) need to be approved by Nov. 1, 2014; and
- The remaining eight required template chapters as well as the template ID card will be sent in the beginning of September.
Both the plans and DOH expressed serious concern over the intense amount of activity slated to take place in the last quarter of 2014. In response, DOH will look to establish more regular communications, including weekly calls with the plans, DOH and CMS.
The FIDA slides also include details of the latest enrollment activities by county, with a total of 130,360 enrollments across all forms of MLTC.
July 2014 Implementing Behavioral Health Managed Care: The DOH presentation focused on the analysis of proposals submitted. Overall DOH feels the submissions were inadequate in terms of meeting the “transformational vision of NYS.” DOH noted the following deficiencies in the applications:
- Majority of responses lacked recovery-oriented and person-centered approach;
- Specifically in the areas of clinical management, utilization management and member services;
- Limited discussion of employment and education services;
- Limited discussion as to why people fail in care and how Plans can affect this;
- Inadequate focus on the unique needs of people with SUD conditions;
- Limited detail on addressing the needs of the SMI/SUD population within the context of BH/PH integration;
- Inadequate discussion on the need to ensure cross system care coordination;
- Discussion of cultural competency in network development and member services was minimal and insufficient; and
- Plan’s projected budgets did not evidence transformational vision; i.e., replacement of BH inpatient with ambulatory services.
DOH will be reaching out to applicants to guide them on how to revise their applications.
Health Home Update
Lana Earl presented on the status of health homes and the data dashboard being developed in conjunction with Salient (no slide presentation available for posting at this time). There will be an Aug. 11 meeting to discuss the bridge proposal to develop alternatives for members who may or may not choose to participate in health homes.
The Salient Health Home dashboard will present utilization and quality data on both health homes and the Delivery System Reform Incentive Payment (DSRIP) program. The new portal is called the Medicaid Analytics Performance Portal (MAPP), and will begin initial data presentation in August with full implementation expected by the end of the year.
July 2014 Oncotype DX: Effective Oct. 1, 2014, Medicaid will begin covering Oncotype DX, a specific genetic test that is performed by only one lab in the State—Genomic Health, Inc., for patients with invasive breast cancer. The State has negotiated a fee-for-service rate with this lab of $2,049 per test, which is 60 percent of the Medicare reimbursable amount. With only one source for the lab testing, the plans recommend that the negotiated rate apply to managed care as well.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827