Managed Care Policy and Planning Meeting
The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on June 11 in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:
June 2015 Mainstream and MLTC Rate Updates
June 2015 FIDA and MLTC Update
June 2015 Behavioral Health Transition
General Information
Jason Helgerson, state Medicaid director with the Department of Health (DOH), started the meeting with a report on a recent national Medicaid director’s conference in Chicago. The Centers for Medicare and Medicaid Services (CMS) notice of proposed rule-making (NPRM) on Medicaid managed care was a significant topic of discussion. CMS has posted a fact sheet and link to the complete NPRM entitled Medicaid and CHIP Managed Care Proposed Rule CMS-2390-P.
DOH intends to submit comments on the NPRM by the July 27, 2015 CMS deadline. They are interested in having plan input to help inform their own comments and would seek to put together a meeting to discuss the NPRM. Overall DOH expressed confidence that many of the provisions in the NPRM are already in place in New York or can be readily implemented. However, Mr. Helgerson reported that New York shares a concern with many other states regarding the aggressive federal timelines for implementing some of the NPRM changes. This aggressive timeline is driven in part by the constraints placed on the current White House to implement policy changes far enough in advance of the end of the current President’s term.
The NPRM, also referred to as the “Mega Rule” touches on all aspects of Medicaid managed care and was prompted in part by the recognition by CMS of how rapidly and dramatically the transition to managed care in Medicaid has swept across the country. The rule touches on a wide range of issues, in many cases driven by concerns from enrollee advocacy groups, including: appeals and fair hearings, encounter data reporting, provider credentialing, mandated timeframes for processing issues, quality ratings and measures, and drug formularies. LeadingAge NY has already met with our PACE/MLTC Cabinet and we have begun to formulate our own comments. Please be sure to share any concerns or comments you have with us (see Contact below). The plans noted during the meeting concern that pharmacy provisions would undermine the integrity of formulary standards and result in increasing costs.
Valencia Lloyd, director, Division of Health Plan Contracting and Oversight, noted that there seems to be an increase in the response time to member complaints. DOH believes that the increase in response time seems to coincide with the increases in enrollment. Ms. Lloyd noted that DOH has encountered delays in plans responding to complaints from members that are forwarded to plans for follow through. DOH noted that currently plans are required to respond within 15 days with an acknowledgement of the complaint. While it is not expected that the plan will necessarily have a resolution within the timeframe, DOH is noting that even an acknowledgement of the referral is often delayed. If the trend continues, DOH cautioned that they would begin citing plans. DOH noted that most of the issue seems to be coming from the Mainstream side.
On a related note, DOH also noted increasing concerns from providers on the processing of claims. DOH instructed plans to review their procedures with the goals of ensuring the timely processing of claims.
The most recent contract amendments are due out shortly. DOH will send the amendments to the associations first and then follow up with a meeting in approximately three weeks for comments and any recommended changes.
Mr. Helgerson provided the update on the Delivery System Reform Incentive Payment (DSRIP) Program, noting that final payments to the Performing Provider Systems (PPSs) will be released shortly. All the approved PPSs are now up and running. Mr. Helgerson went into detail on the exchange of health information in DSRIP. Plans will have access to PPS protected health information (PHI) level data on PPS covered individuals. The system for health exchange will mirror the process currently in place for Accountable Care Organizations (ACOs) with CMS approval required. Patients will be provided with the ability to opt out of the data sharing process. DOH will need to notify upwards of 6 million individuals by letter of their opt out option. There will also be a call center and stakeholder outreach meetings. It is important to remember that opting out of the data sharing does not mean that the individual has opted out of DSRIP.
This data sharing will apply to downstream providers and health homes as well, with the goal of providing meaningful and actionable information. DOH envisions this as two-way flow of information between the PPS and the plans/providers.
DOH will be providing plans with information on their enrollees DSRIP assignments.
The plans noted that there needs to be additional communication and coordination between themselves and the PPSs and that more is needed from DOH in terms of encouraging these relationships. DOH discussed the need for an increased role for plans in DSRIP, including the flow of funds to PPSs through the plans. DOH needs to seek methodologies to flow parts of both DSRIP and Vital Access Provider (VAP) funding through the plans, with plan administrative costs revised to reflect the increased costs.
Regarding VAP funding, DOH is seeking a process to include value based payment principles in the funding. In other words, VAP funding needs to be contingent on the recipient demonstrating increasing quality and DOH would seek to have plans assist with moving VAP payments towards a VBP process.
DOH noted that they are interested in ascertaining plan costs associated with the implementation of DSRIP and would seek to include those costs in the rate setting process.
The plans also requested a point person at the enrollment broker, Maximus, to direct consumer complaints, noting that there is currently some confusion for enrollees seeking to address issues with both enrollment and the Conflict Free Enrollment and Evaluation Center (CFEEC) process.
The plans also reiterated concern over the lack of hospital information on qualified health plans (QHP). DOH acknowledged the need for information and that the timeframe is becoming tight.
Mainstream and MLTC Rate Updates
Please see the linked rate schedules. DOH will implement new transparency requirements allowing plans a 30-day comment period on proposed rates.
Basic Health Plan Rates
The Basic Health Plan rates are now being reconfigured to reflect 4 premium groups as follows:
Aliessa (ages 21-64) will be divided between those at less than 100 percent of the federal poverty level (FPL) and those between 100 and 130 percent of the FPL.
The QHP premium groups (ages 19-64) will be divided between individuals at 139-150 percent of the FPL and those at 150-200 percent of the FPL.
DOH stated that at this time they are not able to standardize the age groups between the Aliessa and QHP premium groups.
Fully Integrated Duals Advantage (FIDA) enrollment stood at 4,407 as of June 2, with 47,702 opt outs. The FIDA enrollment has actually decreased from the 5,920 reported as of May 1. The opt outs have increased from 44,502 during the same period.
DOH announced that the July 1, 2015 date for FIDA plans to submit their alternative payment proposals has been extended to August 15, 2015 (slide 6). The plans asked that the FIDA alternative payment implementation be more closely aligned with the State’s Value Based Payment Roadmap, which would allow for a closer alignment of incentives an provide FIDA plans with more time to develop their proposals.
DOH has released Managed Long Term Care (MLTC) Policy 15.01 – Social Adult Day Care (SADC) Implementation of New Social Adult Day Care Certification Process. DOH also posted the related webinar and frequently asked questions (FAQ).
Slide 8 provides the latest plan and enrollment data, noting 140,886 enrollees statewide across 70 plans, including MLTC, FIDA, Program for All-inclusive Care for the Elderly (PACE) and Medicaid Advantage Plans (MAP). The majority of individuals (129,941) are enrolled in MLTC.
Slide 9 provides a map of the remaining counties that need to transition to mandatory managed care for home and community based services recipients. CMS approved the following counties for transition in June: Essex, Chemung, Chautauqua, Hamilton, Schuyler, Seneca, and Yates. DOH will close the “Front Door” for those new to community-based long term care (CBLTC) services on June 19, 2015. As of June 22, 2015, new users in these counties will go be referred to NY Medicaid Choice (Maximus) and will also go through the CFEEC process. (Please note that the State has subsequently announced that CMS approval has been received for all remaining counties to transition and that effective July 1 mandatory managed care coverage for all home and community based services will be statewide and include: Alleghany, St. Lawrence, Jefferson, Lewis , Franklin and Clinton counties.)
Slide 12 provides a graphic on the 23,331 CFEEC evaluations completed through June 1 with 98 percent of evaluations resulting in approvals.
DOH thanked plans and associations for input on proposed FIDA Interdisciplinary Team (IDT) policy and noted that they are currently in the process of reviewing the comments. DOH recently released a draft document on proposed changes to the FIDA IDT policy. This policy spells out the requirements for the IDT process, which is to be administered by the managed care FIDA plans and is analogous to the care planning process in the nursing home or home care. LeadingAge NY comments on the proposed changes are available by clicking here.
DOH is drafting an announcement letter plans involved in behavioral health (BH) the Health and Recovery Plan (HARP) programs, advising members of the carve in. Please see the linked slides for details on the readiness review process, set to begin June 22 for HARP plans and later for Mainstream and HIV special needs plans not participating in HARP. The RFQ for the rest of the state is scheduled to be released by June 30, 2015, with a due date in September.
The Health Insurance Portability and Accountability Act (HIPAA) Electronic Data Interchange for EDI 834 Benefit Enrollment and Maintenance is used by insurers to enroll members in a healthcare benefit plan. Specifically, the 834 transaction may include the following:
- New enrollments
- Changes in a member’s enrollment
- Reinstatement of a member’s enrollment
- Disenrollment of members
DOH noted that they are finding issues with the 834 transactions and cited the most common reasons for discrepancies between plan records and eMedNY:
- Late renewals
- XT transactions (maintenance transactions are now excluded and handled at local district level)
- Failure to Process 834
- Not knowing Renewal Date
- Case open in both the Welfare Management System (WMS) and eMedNY at the same time
- Duplicate accounts
- Failure to submit effectuations
- Restacking Issues with eMedNY
DOH noted in particular that there are still issues with the coordination of data between the WMS and eMedNY. The accuracy and timeliness of 834 transactions is critical to ensure continuity of coverage for enrollees and the flow of payments to the plans. One key step that plans can follow to ensure the accuracy of 834 data is to be sure to populate the end dates of coverage and to be sure to accurately track renewals. DOH is asking plans to look at their 834 processes relative to the most common reasons for discrepancies and help minimize issues with member enrollments and renewals.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827