Managed Care Policy and Planning Meeting

The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Thurs., Jan. 8 in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:

January 2015 Agenda
January 2015 MLTC, FIDA and Health Homes Update
January 2015 Patient Centered Medical Home
January 2015 MLTC Rate Status and Timeline
January 2015 Mainstream Managed Care Rate Status & Timeline
January 2015 MMC and HIVSNP Rate Development
January 2015 MMC and HIVSNP Additional Rate Data
January 2015 Basic Health Program
January 2015 Implementing Medicaid Behavioral Health Reform in New York
January 2015 Overview of DOH OHIP Organizational Structure

Of special interest, please note the MMC and HIVSNP Additional Rate Data document. This is the extensive data source the Mercer representatives cited during the meeting, detailing the fundamental data and assumptions underlying the mainstream plan basic rate development discussed in the MMC and HIVSNP Rate Development presentation.

General Information

Jason Helgerson, State Medicaid director, opened the meeting by welcoming Valencia Lloyd, director of Health Plan Contracting and Oversight, back after a medical leave of absence. 

Mr. Helgerson also explained that there is some disruption in operations at DOH at this time due to the fact that the Divisions of Health Plan Contracting and Oversight and Long Term Care are in the process of moving to One Commerce Plaza, 16^th floor.

Continuity of Care Analysis: DOH has been carefully monitoring any potential issues with continuity of care during the transition of home and community based services to managed care. The analysis of three months of data demonstrates that there have not been any significant areas of concern and the monitoring will be discontinued.

Nursing Home Transition – Sun., Feb. 1, 2015

DOH confirmed that Sun., Feb. 1, 2015 is the official date for beginning the transition of nursing home population and benefit into Medicaid managed care. As previously announced, the downstate transition of new permanent nursing home placements will now occur in two phases with the transition in New York City boroughs (Phase 1) commencing on Sun., Feb. 1, 2015. New permanent nursing home residents in Nassau, Suffolk and Westchester counties (Phase 2) will be required to enroll in a Medicaid Managed Care or Medicaid Managed Long Term Care Plan beginning on Wed., April 1, 2015. The rest of the State (Phase 3) will transition starting Wed., July 1, 2015.    

Starting in October 2015, nursing home residents not mandated to join a managed care plan (i.e., those grandfathered into Medicaid fee-for-service as permanent nursing home residents prior to the transition date) will be able to do so voluntarily.  DOH announced that they intend to host a webinar on the nursing home transition on Thurs., Jan. 22 at 10 a.m. DOH sent the webinar details to facilities on Thurs., Jan. 15 with a unique log-in for each facility.

DSRIP

DOH announced some important dates regarding Delivery System Reform Incentive Payment Program (DSRIP) Performing Provider Systems (PPS). The current 25 PPS applications are posted for a 30-day public comment period and can be accesssed by clicking here. The first mandatory PPS meeting was held on Fri., Jan. 16 to provide the PPS with the template for their implementation plans that are due in March. DOH is setting aside the dates of Tues., Feb. 17- Fri., Feb. 20 for the Oversight Panel to hold the first public hearings on the PPS plans allowing for modification of the subjective aspects of the PPS plans. DOH noted that all 25 PPSs met the minimum scoring requirements needed to proceed to the next phase of implementation. DOH anticipates starting monthly PPS meetings and eventually holding joint meetings between the PPS and the managed care organizations. DOH is still looking at an April deadline for submitting their plan on the integration of DSRIP and managed care to the Centers for Medicare and Medicaid Services (CMS).

COPA and Regulatory Relief

DOH extended the deadline for PPSs to submit Certificate of Public Advantage (COPA) applications to Sun., Feb. 1, 2015.  They reported not receiving any applications, most likely due to the tight timeframe for the initial deadline. DOH anticipates final approval of COPA applications by Tues., June 30, 2015.

DOH is also looking at the recommendations submitted for regulatory relief under DSRIP, with most of the recommendations focused on measures to integrate physical and behavioral health. LeadingAge NY submitted our recommendations on behalf of our members. DOH is looking at an expedited process to review and approve specific recommendations.

In the area of regulatory relief, DOH is taking their own steps to look at ways of more fully integrating physical and behavioral health.  Currently, the plans are required to pay Behavioral Health Organizations (BHOs) based on government rates for two years (see additional details below). DOH is also looking at possible regulatory relief in terms of allowing for more than one service to be a paid on the same day and to structure payment along value based purchasing incentives.

Value Based Purchasing Work Group

Fri., Jan. 23, 2015 is the date for the next meeting of the DOH value based purchasing work group. The goal is to develop a “roadmap to value based payment” for submission to CMS prior to Wed., April 1. DOH must meet this deadline in order to incorporate value based purchasing into the April 2015 managed care rate updates, which will require CMS approval. LeadingAge NY is representing our members on this workgroup. DOH also noted that they are looking at the need for any statutory changes necessary to implement value based purchasing and will incorporate those changes in the upcoming State budget proposal.

1115 Waiver

DOH acknowledged that there has been a delay in the renewal of the current 1115 waiver authorizing the current Medicaid Redesign initiatives and DSRIP. The waiver expired as of Dec. 31 and New York is currently operating under a three month extension granted by (CMS). DOH reassured the plans that the delay is routine, resulting from a simple back log at CMS and that renewal of the waiver is expected without any complications. If necessary, CMS can grant additional one month extensions pending final renewal of the waiver.

MLTC, FIDA and Health Homes Update

DOH announced that the Fully Integrated Duals Advantage (FIDA) program is operational in New York City and Nassau County. As of mid-December, 372 people had enrolled into FIDA Plans for an enrollment effective date of Jan. 1, 2015, with 100,000 program announcement letters having been mailed. DOH sent out 90-day passive enrollment letters for an April 1, 2015 effective date. These letters were sent to non-SSI individuals with annual coverage dates of June to August 2015 and for the SSI population with a birthday between January to March. The process includes the initial 90-day notice and follow up at 60 and 30 days. There is no immediate action that enrollees need to take at this time.

DOH shared some preliminary data on the FIDA enrollment activity (see page 3 of the DOH slides).  With the 100,000 announcement letters issued, the call center as of mid-December had received 11,246 inquiries, with 372 “opt-ins” and 3,853 “opt-outs.”  DOH stressed that this is very preliminary data, and certainly too soon to draw any conclusions. If gap between opt-ins and opt-outs were to become the trend, however, it clearly raises concern for the viability of the program. DOH cautioned that if this trend were to continue it would trigger investigation by DOH/Office of Medicaid Inspector General (OMIG) regarding any potentially inappropriate steering of enrollees on the part of plans or providers.

DOH launched the FIDA Ombudsman Program, known as the Independent Consumer Advocacy Network (ICAN), on Dec. 1, 2014. The program serves FIDA, MLTC, and “Mainstream” managed care enrollees who receive long term support services. ICAN supports the entire State and not just the FIDA demonstration region, although most of the call activity has been focused on FIDA issues. ICAN information will be included on DOH enrollee notices, including the contact number: 844-614-8800.

Recent informational releases to the FIDA plans included the remaining four Plan enrollment notices along with the ID Card Guidance, and the Integrated Coverage Determination Notices.

Regarding network submissions of readiness review reports, CMS has agreed to allow plans additional Medicare and Medicaid submissions until Fri., Jan, 30, 2015.

Provider Training Workgroup: Regarding the Provider Training Workgroup, DOH reported that the final core training modules were sent to Lewin for posting on its web portal. CMS and DOH agreed to update the deadline for completing the first training module to Fri., Jan. 30, 2015. Work continues on drafting the other required training modules, including the Americans with Disabilities Act (ADA) and cultural competency topics.

Page 7 of the DOH slides provides the latest statistics on statewide MLTC enrollment, with 139,204 enrollees as of Dec. 1; 85 percent of the enrollees are in the New York City area.

CMS approved the transition of “December counties:” Genesee, Orleans, Otsego, and Wyoming, and announcement letters were mailed at the end of last year. Page 9 of the DOH slides provides a map of remaining counties for transition; they breakdown as follows:

• January 2015: Allegany, Cattaraugus, Chautauqua, Chemung, Schuyler, Seneca, and Yates counties;
• February 2015: Clinton, Essex, Franklin, Hamilton, Jefferson, Lewis, and St. Lawrence counties.

The following MLTC Policy documents were released:

• MLTC Policy 14.08: Paying for Live-In Care Through Personal Care Services and Consumer Directed Personal Assistance Services; and
• Wage Parity - Official Notice of Home Care Worker Wage Parity Minimum Rate of Total Compensation in New York City – Update.

Conflict Free Evaluation and Enrollment Center (EEC): DOH reported that the EEC is now operational in Bronx, New York, Kings, Queens, Nassau, and Richmond counties. Implementation in Westchester and Suffolk is slated for February 2015. Statistics cited: average volume is 394 to 422 calls per day; 74 nurses are on staff; and evaluations conducted to date include: 95 percent approval rate; 1 percent denial rate; and 4 percent consumer no-show rate. For more details on EEC activity please refer to page 12 of the DOH slides.

Patient Centered Medical Home

The linked slides provide details on the add-on amounts for patient centered medical homes effective July 1, 2013 through March 31, 2015. 

MLTC and MMC and HIVSNP Rate Development

DOH provided the latest updates on the MLTC Rate Status and Timeline and Mainstream Managed Care Rate Status & Timeline.

Mercer was on hand to present Fiscal Year (FY) 2015-16 Medicaid "mainstream managed care" and HIV special needs plan base rate development (for rates effective April 1, 2015). As noted above, Mercer referenced the MMC and HIVSNP Additional Rate Data as the data source for the basic rate development. Included in this rate data are changes in adjusted core base data from FY 2013-14 to FY 2014-15 and FY 2014-15 to FY 2015-16 by region and premium group.

A central theme of the Mercer presentation is that they are shifting from a reliance on fee-for-service data to incorporating more plan encounter data as the experience with expanded managed care coverage evolves. For example, the FY 2015-16 pharmacy premiums will be based on historical encounter data for the two year time frame FY 2013-13 and FY 2013-14 and will now be developed at the regional level. Plans raised concern during the meeting that this historical data does not adequately reflect anticipated new drug therapies and changes in risk profiles as the covered population continues to grow. DOH also noted the need to ensure that all drug rebates are being taken advantage of to the fullest extent. DOH will be sharing updated and expanded pharmacy dashboard reports with the plans following the release of the April 1 rates.

Medicaid Managed Care Operating Reports (MMCORs) and Special Needs Plan Operating Reports (SNPORs) for calendar years 2012 and 2013 were used to develop each premium group. Benefits previously removed and priced using supplemental data sources are now reflected in MMCOR experience. Mercer also applied Incurred But Not Reported (IBNR) data to the regional averages; summaries of the IBNR adjustments by region and categories of service are included in the rate data document. 

Among the program changes that will be incorporated into the FY 2015-16 rates are:

• inpatient pricing reflecting revised fee schedules effective Jan. 1, 2014 and Jan. 1, 2015;
• updated outpatient mental health pricing;
• dental coverage;
• changes in prescriber prevails for atypical psychotics and mail order pharmacy;
• medical homes and other benefit changes;
• populations new to managed care as a result of both the Medicaid Redesign and the federal Affordable Care Act (ACA - NY Health Exchange);
• wage Parity;
• basic Health Plan adjustments including the Aliessa population;
• behavioral health initiatives; and
• the nursing home transition of non-dual eligibles.

Trends based on both historical data and economic health care indices will be applied from the midpoint of the base period to the midpoint of the contract period resulting in a total of 33 months for medical services and 30 months for pharmacy.

Non-medical expense adjustments will incorporate administrative expenses, underwriting gains, and costs associated with the health insurance provider fee (for affected plans only).

Basic Health Program

DOH is moving forward with the implementation of a Basic Health Plan (BHP) as provided for under the ACA to expand health care coverage for individuals with incomes between 138-200 percent of the federal poverty limits but who are ineligible for Medicaid; this includes those ineligible due to immigration status. Federal matching dollars of 95 percent depend upon meeting relatively tight CMS mandated time frames. The administration will be including language in its 2015-16 budget proposal to establish BHP rate setting authority. In the first phase of the BHP approximately 250,000 Aliessa enrollees will be transitioned effective April 1, 2015. Please refer to the DOH slides for more BHP details and statistics.

Implementing Medicaid Behavioral Health Reform in New York

DOH continues to adjust the timeline for consolidating managed care and adult behavioral health services in the downstate area. The proposed implementation timeframe (updated since the meeting slide presentation) is:

• March, 2015: Anticipated CMS approval;
• April 1, 2015: NYC implementation: Health and Recovery Plans (HARP) Passive enrollment letters distributed;
• July 1, 2015: NYC enrollment begins;
• Oct. 1, 2015: Rest of State (ROS) Implementation and HARP passive enrollment letters distributed; and
• Jan. 1, 2016: ROS Enrollment Begins

At this point, the Children’s Behavioral Health implementation start remains Jan. 1, 2016.  

The ROS tentative Request for Qualifications (RFQ) timeframe for adult behavioral services is:

• Early 2015: DOH distributes ROS RFQ to Plans;
• Spring 2015: Plans submit RFQ to State and State reviews RFQ submissions; and
• Summer 2015: Plan Conditional Designation Awarded

The State is currently seeking authority to move Mobile Crisis Services into the Mainstream Benefit Package through an amendment to the 1115 waiver as part of the overall behavioral health program. 

They are also reviewing comments received on the draft billing manual released to plans on Dec. 17, and they are intending to release a revised manual to plans, providers and vendors incorporating those comments.

DOH announced a deadline of Feb. 17, 2015 for Plans to submit requested documents related to the readiness review desk audits.

As noted above, there was discussion on the requirement that plans pay government rates to behavioral health providers, including FIDA plans. The BHO slide presentation clarifies that:

Behavioral Health government rates currently apply to Mainstream plan payments to Article 31 Mental Health Clinics. Once the carve-in of adult behavioral health services and HARPs become operational, all Behavioral Health and ambulatory services will be covered by government rates in mainstream and HARPs. The carve-in will include Extended Observation Beds (EOB) in Comprehensive Psych Emergency Program (CPEPs) and FIDA Plans, but will exclude Rehabilitation Services for Residents of Community Residences.

In a subsequent email DOH also outlined* the following steps for the adult behavioral health passive enrollment process:

1. Individuals initially identified by NYS as HARP eligible, who are already enrolled in an MCO with a HARP, will be passively enrolled in that Plan’s HARP. 
2. Individuals identified for passive enrollment will be contacted by the NYS Enrollment Broker. They will be given 30 days to opt out or choose to enroll in another HARP.
3. Once enrolled in a HARP, members will be given additional options to opt out before they are locked into the HARP until the next open enrollment period.
4. Individuals initially identified as HARP eligible who are already enrolled in an MCO without a HARP will not be passively enrolled. They will be notified of their HARP eligibility and referred to the NYS Enrollment Broker to help them decide which Plan is right for them. 

*Source: DOH email

Overview of DOH OHIP Organizational Structure

Finally, Valencia Lloyd presented the linked organizational chart for the Division of Health Plan Contracting and Oversight. A revised chart with phone numbers was requested by the plans.

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