Managed Care Policy and Planning Meeting

The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Aug. 14 in Albany.  For member convenience, we have posted all of the reference materials from the meeting on our website as follows:

August 2014 Final Agenda

August 2014 Global Cap Update

August 2014 Mainstream Rate Package

August 2014 MLTC Rate Update

August 2014 FIDA Update

General Information

Jason Helgerson opened the meeting with a discussion of revised managed care transition timelines.  Two critical factors in the adjustment of the timelines are: 1.) The delay in the Centers for Medicare and Medicaid Services (CMS) approval of the nursing home transition plan; and 2.) The transition of remaining rural counties pending the implementation of Conflict Free Assessment (CFA). 

Nursing Home Transition

The Department of Health (DOH) recently announced that the transition of the nursing home benefit and population into Medicaid managed care in the New York City, Long Island and Westchester regions has been delayed from Aug. 1, 2014 to Oct. 1, 2014.  Based on this delay and the State’s previous timeframes, the assumption at this point is that the transition in the rest of state would begin on April 1, 2015. DOH is currently developing a new timeline and revised policy guidance for the nursing home transition.  The policy revisions are based on input from the associations.

DOH reports that the main concern on the part of CMS regarding the nursing home transition has to do with the use of pool dollars (pools under discussion include: high needs high cost (HNHC), quality and capital).  CMS is still questioning why the pool dollars are necessary.  DOH also raised the issue of concern on the part of nursing homes regarding cash flow.  The plans are currently completing readiness surveys regarding the processing of nursing home claims.  DOH suggested that plans may consider cash advances to nursing homes experiencing difficulties.

CFA

All counties in the downstate area and upstate urban counties have transitioned to mandatory managed care enrollment for all recipients receiving home and community-based services for more than 120 days.  CMS is not at this time approving any further expansion into the remaining rural counties until the State implements CFA.  A revised timeline for transition of the remaining counties will be issued shortly assuming an Oct. 1, 2014 implementation of CFA.  Under CFA, Maximus (aka Medicaid Choice) will assume responsibility for CFCA.  Maximus is currently gearing up for the Oct. 1 implementation date, including the hiring of additional nurses.  Under CFA Maximus will assess all new to Medicaid enrollees for eligibility for the program and will most likely be using the NY Uniform Assessment System (UAS).  The plans will have access to the Maximus UAS, but will remain responsible for doing their own assessment in terms of care planning and determining the level of services.  Should a plan choose to rely on the Maximus UAS for care planning, they would be responsible for confirming that the information is still current and accurate.

QI/VAPP

DOH stated that Quality Incentive/Vital Access Provider Program (QI/VAPP) dollars must be passed through to the home care agency.  In the case of a managed care plan that is already paying the home care agency based on the wage parity base rate, the added QI/VAPP money would have to be used to further increase the payment to the home care agency.  Therefore, the rationale for an MLTC to obtain QI/VAPP funding would be to further augment payments to the home care agency either to be more competitive in obtaining home care contracts or to anticipate future increases in the wage parity base rate.

DISCOs

DOH is in the process of setting up a meeting with the Office of Persons with Developmental Disabilities (OPWDD) to coordinate between plans that seek to become Developmental Disabilities Individualized Support and Care Coordination Organizations (DISCOs) and OPWDD.  There is a sense on the part of DOH that most plans feel confident in their ability to participate as DISCOs.

Health Exchange

DOH is conducting a reconciliation process to compare the NYState of Health Exchange enrollment information with data in the eMedNY system.  This will be a snap shot of 15 to 20 data points on each enrollee to find where there may be discrepancies and make the necessary corrections to the system.  Files are due from the plans by Aug. 19; as the deadline was extended from Aug. 15.  As soon as DOH receives the plan files they will begin the reconciliation with a completion date projected for the end of September.

August 2014 Global Cap Update

John Uhlberg reviewed the status of the global cap.  DOH has been diligent and disciplined in monitoring the cap.  They noted that the overall Medicaid program has remained within the cap despite a significant increase of over 400,000 individuals enrolled.  There has been a steady downward trend in the cost per recipient, which started in 2010-11 and accelerated in 2012-13.  This trend is attributable to several factors, including: 1.) The impact of managed care; 2.) The decrease in pharmacy expenditures; 3.) The elimination of trend factors; 4.) The increase in federal match under the Affordable Care Act of approximately $1.1 billion; and 5.) The decrease in accounts receivable.  Regarding item 5, DOH reports that they have been successful in collections from those providers able to make the necessary payments, thus cutting the accounts receivable balance in half.  The remaining providers present a challenge in that they are most likely not in a financial position to easily afford the repayment.  DOH will continue to work with these providers.  The restoration of the 2 percent provider cuts is still awaiting CMS approval.  DOH is currently appealing a $1.25 billion recoupment from CMS based on audit of the OPWDD payment methodology.  If necessary, DOH will pursue litigation based on the fact that for approximately 20 years CMS had approved the payment methodology that was in place.  If this repayment were to happen it would be outside of the global cap.

August 2014 Mainstream Rate Package

DOH released the following timeline for Mainstream rate updates:

 

Base rates are fixed as of April so the only major update for July is to adjust for cost weights which will be budget neutral.

They noted that there are two critical issues outstanding: 1.) The nursing home mainstream rate cell; and 2.) The pharmacy update and stop loss for high cost drugs, i.e., Sovaldi.  Other states are taking actions to restrict the use of Sovaldi and similar drugs.  The first draft of the recommendations from the work group formed to address the use of the new Hepatitis C drugs is being reviewed by DOH.

The plans are seeing an increase in the number of Supplemental Security Income recipients and the plans were reminded that these individuals still need to go through the local district for enrollment.

August 2014 MLTC Rate Update

DOH presented the following timeline:

Effective Date                                   Rate Description                               Release Date

 

Key DOH MLTC priorities:

Premium Changes

• Impact on Partial Cap vs. PACE plans
• Regional impacts

UAS Transition

• Provide transparency in SFY15-16 rate development process as well as timeline and work plan

Pool Funding

• Impact of Admin and Surplus reductions as well as 2 percent withhold
• Cash flow concerns

Wage Parity

• Continue to monitor
• QIVAPP Questions

Specific concerns around upstate PACE rates were addressed.  DOH will convene a call with PACE plans at the end of August to further review the specifics of the PACE rates and steps they intend to take to address the current situation.  DOH appears willing to provide additional advances from the HCHN pool in order to ease some of the cash flow burden, and this may extend to all MLTCs.    

Aliessa

The Aliessa population is slated to convert in place as of April of next year by leveraging the current managed care system and without the introduction of a new Aliessa-specific plan.  This population will convert to Mainstream and the change-over should be relatively seamless for the recipient.

HARP

The final Health and Recovery Plan (HARP) timeline is still subject to CMS approval, and there is a possibility of some delay, subject to approval from the Governor’s office.  If a delay becomes necessary in the downstate timelines both the HARP and Behavioral Health (BH) HARP would be adjusted together and upstate would also be pushed back accordingly.

All HARP applicants have received an initial response from DOH by both email and regular mail.  In revising the applications, DOH will assign a team to each applicant based on the areas in which the application needs to be revised.  There will be in-person meetings with each applicant.  They do not anticipate the need for any applicant to fundamentally re-write their application as they are seeking to fine tune the submissions.  They hope that this will kick-start the technical assistance phase of the HARP implementation.  They also hope that the current process will inform the additional applicants as the process begins upstate.

Program Integrity

Questions have arisen over the new Office of Medicaid Inspector General (OMIG)/Attorney General (AG) integrity guidelines that require plans to report on suspected (not confirmed) fraud.  DOH will re-engage with the OMIG/AG to address plan questions. 

The plans asked about the ability to reduce some administrative overhead, in particular the need to send out a hard copy of the plan network directory.  DOH will clarify that the plan handbook must be mailed out in hard copy, but the directory may be printed on demand.  DOH and the associations should develop a list of other possible administrative savings.

DSRIP

Regarding the Delivery System Reform Incentive Program (DSRIP), Jason Helgerson reported that James Introne will be taking the lead in meeting with Performing Provider Systems (PPS) to help develop collaborations and facilitate possible future consolidations.  Between now and November, DOH will seek to advise the PPSs of the number of potential covered lives and provide greater clarity on what they consider to be high value projects, including specific attributions and potential needs.  DOH expects to have a scoring tool released for comment next month.  Their goal is to finalize the PPS networks by mid-November.  Plans will play a role in evaluating PPS attributions in terms of providing information on covered lives and the primary care physician.  Among the key attributions are: 1.) Providing value for enrollees; 2.) The number of enrollees served and the performance metrics based on domains; and 3.) The pay-for-performance metrics.  The State will need timely and accurate encounter data and will be engaging plans in this effort.

August 2014 FIDA Update

Plans should be receiving their Medicaid billing ID numbers shortly.  Once received, this number will allow the plans to begin systems testing with eMedNY.  All systems testing should be completed by Jan 2014.  Starting in October, DOH will begin weekly calls with plans to address implementation issues.

Marketing continues to be a concern for plans.  Details on a follow-up marketing meeting in NYC in September will be released soon.  Specifically under marketing DOH noted:

• Chapters 2, 5 and 7 of the marketing manual were released to Plans on 7/18/14 and templates were due back last week on 8/4/14;
• The remaining 5 required template chapters (3, 4, 9, 10 & 12), as well as the template ID cards, will be sent by the beginning of September; and
• Send any marketing questions to FIDA@health.state.ny.us

 Regarding enrollment:

• The State received comments on the draft Enrollment Companion Guide and the final companion guide will be issued at the end of August;
• Phase 2 enrollment notices were sent to advocates and Plans for comment; and
• The State specific Enrollment Guidance is in draft and will be issued by the end of August.

A new policy directive, 14.05, based on a change in Public Health Law 4403-f(7)(a), requires Plans to provide aid-continuing for enrollees without regard to the expiration of the Plan’s prior service authorization.  According to this policy directive:

• Enrollees are entitled to receive previously authorized services unchanged pending the outcome of an internal appeal even if the enrollee’s service authorization period has expired;
• In addition, Plans must also comply with aid-continuing while an enrollee is awaiting a fair hearing decision from the Office of Temporary and Disability Assistance; and
• This change applies to enrollees who were in aid-continuing status on or after April 1, 2014.

DOH noted that per the advice of the A/G, the standard clauses portion of the FIDA three-way contract needs to be revised such that the New York specific clauses appear first in the contract.  Plan will be given official notice of the change.

DOH is also in the process of developing web-based training programs for FIDA plans.

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