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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 Thurs., Feb. 12 in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:

February 2015 Agenda

February 2015 Transgender Related Care and Services: Proposed Regulations

February 2015 FIDA and MLTC Update

February 2015 FY 2016 Executive Budget and Global Cap Update

February 2015 Mainstream Managed Care Rate Status & Timeline

February 2015 MLTC Rate Update

February 2015 Implementing Medicaid Behavioral Health Reform

February 2015 Peer Mentoring in Consumer Directed Personal Assistance Program

February 2015 Rollout of Medicaid Analytics Performance Portal

February 2015 Office of Quality and Patient Safety

General Information

Jason Helgerson, the State Medicaid director, opened the meeting along with Valencia Lloyd, director, Office of Health Insurance Programs and John Ulberg, director, Division of Health Care Financing.

The Nursing Home Transition has been in effect since Sun., Feb. 1, 2015; therefore plans should not be experiencing any managed care disenrollment as a result of patients entering nursing homes. A revised nursing home transition Frequently Asked Questions (FAQ) document is being developed based additional provider input from the Thurs., Jan. 22 Department of Health (DOH) nursing home transition webinar (archived here). DOH is currently in the process of compiling official responses to the more than 200 additional questions generated through the webinar. 

This final FAQ is expected to be posted sometime in the next two weeks. The current FAQ reviewed during the webinar is available here. The 20-page document addresses many outstanding questions that LeadingAge NY had previously submitted to DOH, although we continue to pursue answers to some key unknowns. LeadingAge NY participates on the Nursing Home Transition Workgroup and will keep members informed of further developments.

As a reminder, any Medicaid-eligible individual who is permanently placed in a nursing home in New York City after Sun., Feb. 1 will be required to enroll or remain in a Managed Long Term Care Plan (if dually eligible) or mainstream managed care plan (if Medicaid-only eligible). Enrollment will become mandatory in Westchester and Long Island on Wed., April 1, 2015, with the rest of the State scheduled for Wed., July 1. 

Plan representatives raised concern regarding upstate nursing homes that in some instances are reportedly seeking to negotiate managed care rates at 125 percent or more of the benchmark rates. DOH asked the plan representatives to submit specific cases that they could review in order to evaluate the appropriateness of the arrangements.

There was considerable discussion on the transition of school based health services into managed care to begin Wed., July 1, 2015 (children covered under the Supplemental Security Income (SSI) program, however, are not transitioning until January 2016). School based health programs have the option of either providing services, including Behavioral Health (BH) services directly or subcontracting. For BH services not provided by a Behavioral Health Organization (BHO), the school health program would need to obtain separate authorizations for enhanced or non-routine services. 

Almost 25 percent of school based health centers serve communities where more than one-third of the population lives below 100% of the Federal Poverty Level, and 79 percent of students in schools with centers are non-white with more than 30 percent identified as Black or African-American.

Certain services, for example dental, will remain carved out of the school based managed care program. These services will remain separately billable under Fee-for-Service (FFS). This is also true for reproductive health services, which will also remain directly billable under FFS. This will be further detailed in a school based managed care policy paper currently being developed by DOH.   

DOH clarified that billing for any one visit will be driven by the primary reason for the visit. Therefore, if reproductive health concerns were the primary focus of the visit, then the entire visit will be covered under FFS, even if managed care covered services were included in the visit.

DOH is delaying the implementation of an automated process for the selection of a Primary Care Provider (PCP) until January 2016. The intent is still to incorporate a “point and click” feature that would be available when the member selects a managed care plan. Technical issues have resulted in the current delay. In the meantime, DOH will implement on screen prompts and customer service scripts that will direct members to be sure and select a PCP that is in the plan’s network. 

Although not on the agenda, the plans requested the latest update on the Delivery System Reform Incentive Payment (DSRIP) program. Since questions on DSRIP come up at every meeting, DOH decided to add a standing DSRIP item to the agenda. DOH announced that they have received two Certificate of Public Advantage (COPA) applications They anticipate making a decision on these two initial applications by Wed., April 1, 2015. They are opening a “window” for a second round of applications to be completed by June 2015. DOH acknowledged that the applicants in this initial round experienced some difficulty with completing all the elements. They will be posting the applications and intend to offer ongoing application windows.

Plans expressed concern with the lack of interaction between managed care and the DSRIP Performing Provider Systems (PPSs). DOH acknowledged the concern and stated their intent to coordinate communications. April 1 remains a critical date in terms of DOH needing to report to the federal Centers for Medicare and Medicaid Services (CMS) on their plan to integrate managed care into DSRIP.

The current 25 PPS applications were posted for a 30-day public comment period on Wed., Jan. 14, 2015. The first mandatory PPS meeting was held on Fri., Jan. 16, 2015 to provide the PPSs 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 those plans. DOH had previously 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 PPSs and the managed care organizations.

DOH is “fast tracking” the DSRIP regulatory reform proposals. A joint letter from all the respective commissioners is being drafted for release sometime the week of Feb. 16. All indications are that the PPS can anticipate a significant degree of regulatory relief. Among the more common themes were requests for greater flexibility in the provision of behavioral and mental health services. DOH also indicated that there were very few “hard no’s,” and that in many cases they would be going back to the PPS to amend the request in order to make it more acceptable.

Transgender Related Care and Services: Proposed Regulations

The Office of Health Insurance Programs (OHIP) presented proposed regulations on the coverage for transgender related care and services under managed care as posted in the State Register on Dec. 17, 2014. With the comment period closed, DOH is now in the process of assessing the public input. There is no set implementation date at this time.

For individuals diagnosed with gender dysphoria, the current program essentially covers mental and/or behavioral health services and non-transition related medical services. Under the current proposal, coverage would be expanded to include cross-sex hormone therapy and surgical gender reassignment, including post-transition care. Generally, these services are only available to individuals 18 years of age or older, with sterilization services only available starting at age 21. DOH will need to clarify the eligibility for individuals who fall under the federal Children’s Health Insurance Plan (CHIP) age threshold of 19.

DOH is planning to develop gender codes to specifically designate individuals as "male-to-female" and "female-to-male." For complete details, please refer to the linked slide presentation. A Medicaid Update article that includes codes and billing guidance will be posted once the regulations are finalized. Questions may be directed to the OHIP Division of Program Development and Management at 518-473-2160.

FIDA and MLTC Update

DOH announced that the Fully Integrated Duals Advantage (FIDA) program is operational in New York City and Nassau County (Region 1) with 698 individuals enrolled through the “opt-in” process since Dec. 1, 2014. During last month’s meeting, DOH reported 372 enrollees as of mid-December with 100,000 announcement letters mailed out. DOH did not update the “opt-out” number which was reported as 3,853 during January’s meeting. Plans will recall that DOH had expressed some concern over the very preliminary trend showing a high rate of opt-out versus opt-in.

The passive enrollment notification process remains:

  • The 90-day notice for April passive enrollment was released at the end of December.
  • The 60-day notice for April passive enrollment was released the last week in January.
  • The 30-day notice for April passive enrollment will be released in February.
  • The 90-day notices have been sent for May of passive enrollment in Region I.
  • The 60-day notice for May passive enrollment will be released in February.
  • The 90-day notice for June passive enrollment will also be released in February.
  • Copies of 90, 60 and 30 day notices have been shared with Plans and stakeholders. 

For Region II (Suffolk and Westchester counties), passive enrollment will begin April 1, 2015. Approximately 10,000 program announcement letters will be mailed at the end of February to FIDA eligible individuals in this region. DOH noted that CMS is reviewing the Medicare network submissions for this region and there is some concern that not all plans will be able start marketing on March 1, 2015. DOH will be providing further details as they review the situation with CMS.

Recent DOH communications to the plans have included:

  • updated Enrollment Appendix;
  • the FIDA Brochure in 6 Languages;
  • Plan Point of Contact List;
  • Revised Address Verification Notice;
  • updated listing of NYSDOH-approved Nursing Home Transition and Diversion (NHTD)providers; and
  • final rate information for the Office of Mental Health (OMH). 

DOH is also close to finalizing appeal and grievance notices with CMS.

Regarding provider training, DOH reported that the modules have been approved and the Lewin Group portal is now functional. Discussions on extending the training deadlines and the development of a rollout schedule are in process.

In their update on Managed Long Term Care (MLTC) enrollment, DOH noted that the total number has been stable at around 139,000 individuals for some time and they are in the process of analyzing why growth seems to be leveling off. Of these enrollees, approximately 85 percent are in the New York City area, leaving 15 percent in the rest of State.

There are 13 rural counties clustered in two geographic areas that remain to be transitioned into mandatory managed care enrollment for home and community based services recipients. These counties break down as follows: (1) Southern Tier-Allegany, Cattaraugus, Chautauqua, Chemung, Schuyler, Seneca and Yates; and (2) North Country - Clinton, Essex, Franklin, Hamilton, Jefferson, Lewis and St. Lawrence. 

Regarding the Conflict-Free Evaluation and Enrollment Center (CFE), DOH announced that they are finalizing plans to provide a single point of contact for coordination purposes. Plans asked about the potential conflict of interest in terms of the CFE contractor, Maximus, utilizing contract nurses from licensed agencies to perform evaluations. DOH noted that Maximus is using a combination of employed and contracted staff to perform evaluations and the contracted staff must attest to the fact that they are not employed by a plan or provider. 

Plans also raised concern that some enrollees are experiencing an extended period of time without making a plan choice. Enrollees must be encouraged to select a plan as soon as the screening process is completed. DOH will be looking into why this delay is occurring in some cases. They believe that better enrollee education may be needed. DOH noted, however, that in 98 percent of the cases, the CFE is meeting the 5-7 day turn-around requirement, and in those cases where there has been a delay, it is primarily due to the weather or requests on the part of the enrollee. Fair hearing activity has been low with only two cases pending at this time.

The CFE is operational in Bronx, New York, Kings, Queens, Richmond, Nassau, Suffolk and Westchester counties. Additional statistics cited included: 99 percent approval rate; 1% denial rate; and 4% consumer no-show rate. Please refer to slides 8 and 9 of the linked presentation for additional statistics.

FY 2016 Executive Budget and Global Cap Update

The DOH budget summary included:

  • Global Cap Recap
  • Results through November 2014
  • Closeout Strategy
  • Fiscal Year (FY) 2016 Global Cap Projections
  • MRT Phase V Recommendations

For the complete LeadingAge NY analysis of the Governor’s Executive Budget, please click here.

The $17 billion Fiscal Year (FY) 2015-16 global cap represents annual growth of $540 million, mostly in anticipation of growth in overall costs and enrollments, which are expected to grow by 400,000 over March of 2014. The 400,000 new enrollees include a projected 140,000 enrollees due to the Medicaid expansion under the federal Affordable Care Act (ACA), which are 100 percent federally funded. The budget also projects a cap of $17.7 billion in FY 2016-17, reflecting a growth of $779 million.

For the current FY, which ends on March 31, 2015, the State is running $10 million (0.9 percent) below estimates and expects to come in under the cap. This is positive news for providers who might otherwise incur rate cuts in order to come under the cap. There will be no global cap dividend this year.

The MRT budget also includes provisions to enhance the collection of approximately $248 million in accounts receivable owed to the State from providers. Under this initiative, DOH is seeking to reduce all outstanding A/R liabilities by March 31, 2017, with providers being required to submit proposals to achieve full recovery over the next two years.

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 MRT budget also reflects the Executive Budget provisions that include Vital Access Provider program funding of $952 million for FY 2015 and $852 for FY 2016. Other MRT provisions discussed included the pharmacy initiatives and Hospital Quality and Essential/Rural Community Provider Investment as found in the proposed Executive Budget.

Plans raised two specific concerns regarding the 340B and transportation carve-out proposals. The concern regarding the 340B proposal is that the plans are not in a position to be aware of whether or not a provider is participating in the 340B program making it very difficult for the plans to enforce the proposal with providers.

The plans are also concerned that carving out the transportation may impact the quality of service. Under the current program, plans are able to negotiate both price and quality of service. There is concern that plans will lose control over the quality of service under the carve-out proposal.

Related to the budget, DOH discussed the need to accelerate the collection of rebates based on increased audit scrutiny. Mercer needs to implement a process for incorporating rebates into the actuarial analysis. 

Regarding Hepatitis C drugs, DOH is keeping the clinical criteria consistent, but is relying on plans to negotiate rates and cover the cost.

DOH is interested in further discussions with plans on the several budget issues, including the 5 percent cap on profits and further discussions on the best process to manage quality pool funds.

DOH advised that the Controller’s office is becoming more involved in managed care issues, but they do not necessarily fully understand the complexities of the Medicaid managed care process, specifically in terms of understanding the nature of risk based reimbursement.   

The administration has included 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. The magnitude of the BHP at $945 million with the large federal match makes the success of the program the “lynch pin” to meeting the State’s Medicaid budget goals. This is especially critical given the difficult nature of overall hospital finances. The plans noted that the biggest risk for the BHP is accelerating hospital costs, especially as Medicaid rates begin to approximate commercial rates.

Mainstream Managed Care Rate Status & Timeline

DOH announced that the April 2014 rate updates will be in the March 4, 2015 checks and CMS approval on the July 2014 rates is expected in the next two weeks. DOH acknowledged that the 2 percent Aliessa reduction was an error and will be restored. 

The nursing home benefit has been available in the mainstream package, but the nursing home enhancement will not be incorporated into the separate rate cell until chronic care budgeting is established for the enrollee with retroactivity to Feb. 1, 2014.

Please refer to the linked document for the complete timeline, including additional details on the BHP and remaining open items. One important open item is developing a mechanism to capture BHP enrollee and claims data on the MMCOR. For enrollees, BHP cards will at least initially appear the same as regular Medicaid cards.

MLTC Rate Update

The $70 million in Quality Incentive Vital Access Provider (QIVAP) pool funding for FY 2014 to be paid as a retroactive lump sum for NYC plans as a pass through for wage parity is still pending. 2014 mandatory MLTC rates are still pending with the Department of Budget and CMS. DOH acknowledged the need to incorporate the nursing home benefit and develop a process for managing the transition from the SAAM to the UAS.  DOH is considering the recommendation from plans to include a phase-in transition process.

It remains unclear at this time as to how a pool may be implemented to balance out those plans contracting with high capital cost nursing homes. DOH is seeking to evaluate how relationships will evolve between plans and nursing homes to determine the extent to which such a pool may be necessary. It was also noted that CMS has yet to approve the pool.

Please see the linked document for further details.

Implementing Medicaid Behavioral Health Reform

DOH announced that there is no official date for the submission of the upstate Request for Proposals. For downstate, DOH is working with CMS for an anticipated end of March waiver approval, including the special terms and conditions.

Key outstanding issues include Conflict Free Case Management pending CMS approval and premium approvals.  HARP/mainstream desk audit deliverables are due on March 9, 2015. The target timeline for downstate includes NYC on-site reviews April-May 2015 and readiness reviews in June. 170 NYC providers applied for the Home and Community Based Services (HCBS), covering multiple HCBS. DOH will be releasing a list of designated NYC providers shortly. With comments submitted by plans, DOH is seeking to update the billing manual by the end of February. DOH is also reviewing BH regulatory requirements to ensure appropriateness in a managed care environment.

Peer Mentoring in Consumer Directed Personal Assistance Program

This presentation focused on the process for peer mentoring in the Consumer Directed Personal Assistance Program (CDPAP). The presentation stresses that there is increased satisfaction for CDPAP participants. The peer mentoring program provides support and guidance to participants who may not have supervisory experience or confidence in managing a caregiver.

Rollout of Medicaid Analytics Performance Portal

The Medicaid Analytics Performance Portal (MAPP) for the Health Home Program is a performance management system that will provide analytical and statistical tools to support providing care management for the Health Home (HH) population and the DSRIP performance management technology needs. DOH anticipates a February-March rollout of demos and the release of training tools in mid-March. Mid-April is projected as the “go live” date.

Office of Quality and Patient Safety

The Office of Quality and Patient Safety (OQPS) is the focal point of quality and safety initiatives for DOH and related agencies.  OQPS takes the lead in the areas of data, health information technology (HIT) and evaluations. The OQPRS is also the lead agency in developing specifications and analysis for DSRIP. In the area of HIT, OQPRS directs the SHIN-NY and sets standards for meaningful use. For a complete summary of the role of OQPRS please see the linked slides.

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