Managed Care Policy and Planning Meeting
The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on July 9 in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:
July 2015 FIDA and MLTC Update
July 2015 Mainstream and MLTC Rates Schedules
General Information
This was a relatively short meeting, adjourning around lunch time.
Valencia Lloyd, director, Division of Managed Care opened the meeting advising plans that they will be receiving a document submission request from the Division of Legal Affairs arising out of class action litigation brought against the New York State Department of Health and NYS Office of Temporary and Disability Assistance (Taylor vs Zucker, U.S.D.C., S.D.N.Y. filed July 15, 2014). The plaintiffs in this case are challenging whether timely and adequate notices of denial, reductions, and terminations were issued to enrollees in managed care organizations and allege that there was not adequate opportunity for a Fair Hearing and aid-continuing in violation of the Due Process Clause of the United States Constitution and the Medicaid Act.
- Expanded Role for Plans
Jason Helgerson, state Medicaid director and deputy commissioner, presented his concept that the managed care plans should play an expanded role in support of special State payment initiatives. For example, Mr. Helgerson noted that there are 26 hospitals that are experiencing “tremendous financial challenges.” The State budget currently authorizes $245 million in State-only dollars to assist these providers and the Department of Health (DOH) is estimating that an additional $80 million dollars may be needed for a total of $325 million. By having the funds flow through the plans DOH can draw down additional federal matching funds, significantly enhancing the amount of dollars available for relief. The current plan is to channel the funds through the plans to the Delivery System Reform Incentive Payment Program (DSRIP) Performing Provider Systems (PPS) organizations and finally to the designated providers.
DOH is currently developing the specifics of the proposal in conjunction with Mercer, counsel, and plan and hospital associations for a projected August implementation start. In response, the plans requested a letter from DOH establishing the basis for the payments and indemnifying the plans in the event of an adverse determination from the federal Office of the Inspector General. DOH agreed to provide such a letter.
Plans also raised concern that these categories of enhanced payments could adversely impact their payments if current rate ranges are exceeded. DOH will monitor the situation in the event that this causes any problems with actuarial modelling. Specifically, the plans requested an exception to the general administrative caps.
Mr. Helgerson noted that plans can play an important role in supporting initiatives on the part of the PPSs to transition the system towards Value Based Payments.
- LHCSA Physician Orders
In response to complaints raised by the Licensed Home Care Services Agencies (LHCSAs), Mark Kissinger, director, Division of Long Term Care, reiterated the policy for the sharing of physicians’ orders as specified in DAL HCBS 13-15 Clarification Regulatory Requirements of LHCSAs. As noted in this guidance: “As such, there must be an order from the patient’s authorized practitioner and documentation must exist at the agency for the health services the agency provides to those patients. The contract between the LHCSA and the MCO or MLTCP must clearly indicate where the information will be maintained and how the LHCSA will access.” Plans responded that some contracts may specify that the LHCSA directly procure and maintain the physician orders.
- Social Adult Day Care Certification
Mr. Kissinger also noted that the Office of Medicaid Inspector General (OMIG) will be issuing a Q&A reference in response to the recent Social Adult Day Care (SADC) Certification webinar. DOH will be releasing a listing certified SADCs in the next few weeks. Additional certifications depend in part on final approval of legislation that would create a licensure requirement for all programs. DOH advised that the plans must decide whether or not to continue contracts with SADCs that are not certified.
- DME
Plans continue to seek clarification on the policy for Durable Medical Equipment (DME) prescribing. DOH agreed to set up a meeting with OMIG to determine when a prescription is needed for DME supplies/items that are already included in the plan benefit package.
- DSRIP
Mr. Helgerson presented on the DSRIP update standing agenda item and noted that the posting of the DSRIP timeline has been updated to align with the anticipated posting to the PPS Partner Networks.
Plans asked DOH for an update on the Certificates of Public Advantage (COPA) and the impact on current regulations. DOH anticipates release of final regulations as of September. There are two applications that are still under review, with a third application having been withdrawn. After meeting with the Attorney General’s Office, DOH is confident that the applications will be ready for review at the Public Health and Health Planning Council (PHHPC) meetings slated for September/October. The public may comment on COPA applications in person at a PHHPC committee meeting. DOH noted that they have not taken a position on the Erie County Medical Center Antitrust Legislation that is currently awaiting the Governor’s signature.
The PPSs continue to fine tune their implementation plans. All 25 plans have some additional items that need further refining or clarification, but none of these are characterized as serious by DOH.
DOH is hoping to initiate regular meetings between the plan and PPS chief medical officers to begin to determine clinical areas of coordination.
After several revisions, DOH anticipates that the Centers for Medicare and Medicaid Services (CMS) will be approving the current Value Based Payment Roadmap. DOH is now seeking recommendations on clinicians to serve on the VBP clinical advisory work group. DOH is also looking at the type of data that will need to be collected in order to verify that plans are in compliance with the eventual goal of 90 percent of payments based on VBP.
DOH is developing their recommendations to CMS on how to align the Managed Long Term Care (MLTC) program with the PPS goals under DSRIP. Given the emphasis on reduces post-acute care re-hospitalizations, DOH acknowledges the significant role that MLTC plans will play in achieving DSRIP objectives.
DOH also noted that they are once again accepting applications under the DSRIP regulatory waiver process and decisions are still pending on some of the applications submitted in the first round, including requests made by PPSs related to Certified Home Health Agency and Hospice expansions. The waivers will be reviewed in the context of their DSRIP project plans and/or the Capital Restructuring Financing Project, (CRFP) with applications due by Sept. 15, 2015. Please also note that DOH intends to announce the CRFP awards this October.
DOH presented data the most recent Fully Integrated Duals Advantage (FIDA) plan enrollment numbers:
FIDA Enrollment Update – July 1, 2015
FIDA Enrollment NY Medicaid Choice Calls Received Total Opt-Outs
6,368 88,705 51,328
You may compare the numbers with last month’s statistics:
FIDA Enrollment Update – June 2, 2015
FIDA Enrollment NY Medicaid Choice Calls Received Total Opt-Outs
4,407 82,879 47,702
During this period, enrollment increased by 1,961 while the number opting out increased by 3,626 (Source: DOH FIDA and MLTC Updates).
Page 3 of the DOH slide presentation includes the following passive enrollment schedule:
July 1:
2,599 individuals were enrolled.
August 1:
60 day letter was sent May 26, 2015.
30 day letter was sent June 24, 2015.
4,211 individuals are set to be passively enrolled.
September 1:
60 day letter was sent June 23, 2015.
30 day letter will be sent July 23, 2015.
1,721 are set to be passively enrolled.
DOH anticipates that there will be additional waves of passive enrollment as they seek to include individuals not captured during these initial periods.
Approximately 150 people participated in the June 18 FIDA outreach program held in conjunction with CMS. The roundtable for plans and providers included an overview of FIDA and a panel of FIDA plan medical directors discussing the benefits of the program. DOH is developing a white paper designed to support changes to the program that would support greater enrollment. No specifics have been shared with CMS, but DOH believes that they would be receptive to making changes that would enhance enrollment. The draft should go out to stakeholders for comment sometime in the Fall.
The All Payer Database Team presented updated encounter data and FIDA plans may begin testing once connectivity is established.
Encounter Data update presentation by the All Payer Database (APD) Team. FIDA Plans can begin testing once connectivity has been established.
Page 6 of the DOH slides presents a break-down of the current Medicaid MLTC enrollments across plan types and the number of plans in each category. There was a slight uptick in the number of total enrollees statewide from 140,886 reported last month to 143, 963. Statewide, CMS has approved all counties for mandatory enrollment as of July 1. This coincides with the implementation of mandatory enrollment for new nursing home admissions in the rest of state. New applicants in the remaining counties of Allegany, Clinton, Franklin, Jefferson, Lewis, and St. Lawrence will now be referred to the Conflict Free Evaluation and Enrollment Center (CFEEC) for clinical eligibility determinations. The CFEEC under Maximus is now operating statewide with an overall approval rate of 98 percent.
Since the last Policy and Planning meeting, DOH has release the following new policies:
- MLTC Policy 15.02: Transition of Medicaid Managed Care to MLTC
- MLTC Policy 15.03: End of Exhaustion Requirement for MLTC Partial Plan Enrollees
Mainstream and MLTC Rates Schedules
Please see the DOH schedules for details on the projected Mainstream and MLTC rate updates.
For MLTC rates, DOH is close to a final reconciliation of the Quality Incentive Vital Access Provider (QIVAP) pool funding. DOH will post the final amounts broken down by provider and plan; however, CMS approval is not expected for a few months. DOH has contracted with IPRO to review the allocations and conduct any necessary audits. They are currently in the process of evaluating whether to continue the program beyond the current funding period.
The Division of Budget (DOB) and CMS are reviewing the Quality Pool awards for the April 2014 rate update. DOH noted that the state share of the award may be released in advance of final CMS approval pending approval from DOB.
DOH hosted a webinar of the draft April 2015 Phase 1 rates and has issued the actuarial memorandum for a 30-day comment period.
Decision on UAS Phase In
LeadingAge NY is pleased that the Phase 2 rates will include a blending of the SAAM and UAS risk scores at 75 percent SAAM and 25 percent UAS. In the third phase, rates effective July 2015 will have a 50/50 blend. Based on input from our plan members this is the implementation process proposed and supported by LeadingAge NY.
Regarding Mainstream rates, DOH is projecting that the April 2015 rates will include the nursing home carve-in adjustment. DOH has already completed the release of the actuarial memo and conducted a webinar and they anticipate submission to CMS on July 30, 2015.
Behavioral Health/HARP
The Office of Mental Health (OMH) released the RFQ for the rest of state on July 3, 2015, along with an abbreviated RFQ for plans already certified in NYC on July 10. For both NYC and rest of state, the timeframes for processing applications and approvals are very tight. Plans should reference the slide presentation from the June 2015 Policy and Planning meeting for details on the current implementation timelines.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827