MMCARP Meeting Focuses on Managed Care Enrollment Issues
The Department of Health (DOH) hosted a Medicaid Managed Care Advisory Review Panel (MMCARP) conference call on Fri., June 20, focusing on critical managed care enrollment issues. The two-hour teleconference covered the following agenda:
- Program Update and Review of Minutes
- Review of April 24, 2014 Minutes
- Program Update Managed Care
- Enrollment Discussion
- Highlight of Proposed Model Contract Changes for Vulnerable Populations
- Presentation of OPWDD Waiver/DISCO/Listing of OPWDD Advisory Panel Members
- Public Comment
Please note the next scheduled MMCARP meeting is Sept. 17 from 10 a.m. to noon.
Valencia Lloyd, director, Division of Managed Care at DOH initiated the teleconference by announcing that overall enrollment numbers for all Managed Care Organizations (MCOs) are growing. In this case, MCOs included mainstream managed care, Managed Long Term Care (MLTC), and the NY State of Health health exchange enrollees.
Health Exchange Enrollments
In particular, DOH noted that the health exchange numbers are doing well and that we should start to see declining enrollment in Family Health Plus, as the health exchange numbers increase. Although the decline in Family Health Plus enrollment is lagging behind the growth in exchange enrollment, the downward trend in Family Health Plus should accelerate as we approach the phase-out of the program, and everyone is moved to exchange plans.
DOH also noted that due to problems with the health exchange auto-enrollment algorithm, auto-assignments into plans through the exchange are on hold. Approximately 15,000 individuals were enrolled before auto-assignment was suspended. They also emphasized, however, that regardless of the managed care plan type, auto-enrollment continues to represent only a small percentage of the plan assignments and the vast majority of current enrollees actively selected their own plan.
The committee requested and DOH agreed to provide a detailed breakdown of the enrollment numbers between upstate and downstate for the exchange and Family Health Plus.
FIDA Nursing Home Transition
DOH will provide additional clarification on the transition of nursing home residents into MLTC in the Fully Integrated Duals Advantage (FIDA) region, essentially NYC, LI and Westchester. A recent statement by DOH indicated that should the current transition date of July 1 have to be moved much closer to the Jan. 1 FIDA implementation date, DOH may forego the interim MLTC enrollment of new nursing home admissions and simply wait for the FIDA passive enrollment of all nursing home residents. This will not impact nursing home residents in the rest of state. While this strategy is currently under consideration, DOH has not made an official decision.
Enrollment Broker and Enrollment Update
According to DOH, at this time there are 43 counties signed on to use Maximus (Medicaid Choice) as their enrollment broker. The remaining counties that continue to process enrollments through their Local Departments of Social Services (LDSS) tend to be the smaller, rural counties that are not likely to experience a large number of enrollments.
However, the State continues to encourage all counties to sign on with Maximus. Proposed legislation in the 2014-15 state budget would have mandated such, but this was rejected by the legislature. Beginning in July, Broome and Yates counties will be the latest counties to use Maximus.
MLTC Enrollment
In the downstate region and upstate urban counties, MLTC enrollment is now mandatory for beneficiaries requiring over 120 days of home and community-based services. The next round of counties to transition to mandatory MLTC enrollment is pending approval from the Centers for Medicare and Medicaid Services.
The following are recent DOH MLTC enrollment numbers for NYC and Rest of State and by plan type:
|
Statewide Enrollees in MLTC |
As of 5/1/14 |
|
NYC: |
113,184 |
|
ROS: |
16,705 |
|
TOTAL: |
129,889 |
|
Statewide Enrollment by Plan Type |
As of 5/1/14 |
|
Partial Cap |
118,830 |
|
PACE |
5,719 |
|
MAP |
5,340 |
|
TOTAL: |
129,889 |
Source: June 12, 2014 DOH FIDA Update
DOH hopes that once begun, the nursing home transition to managed care noted above will be a gradual one. Since the mandate will apply only to new, permanent admissions, and since Medicaid eligibility and personal budgeting criteria will remain in place, DOH does not expect to see a large spike in enrollment during first couple of months of the transition. For the non-FIDA regions, this will likely remain the case for several months.
Fee-for-Service Figures and Managed Care Enrollment
DOH reported that for individuals whose Medicaid eligibility is not based on Modified Adjusted Gross Income (MAGI) criteria, the rate of managed care enrollment increased from 2.2 percent in 2013 to 8.2 percent in 2014. For the health exchange, the number of enrollees increased from 33,000 in Jan. 2014 to 539,000 in June, with 80,000 currently pending. The number of fee-for-service (FFS) enrollees during this same time period dropped from 380,000 to 119,000.
The number in FFS should continue to drop dramatically as the health exchange numbers increase, with FFS eventually being comprised of individuals waiting to be processed into an MCO. The State continues to practice a “no wrong door” policy, initially allowing new to Medicaid individuals to enter the system in either FFS or managed care and then directing them to the most appropriate coverage.
As noted above the Family Health Plus program is being phased out; the latest statistics showing a 15 percent drop from 340,000 to 290,000 since the exchange began operations. DOH stated that the transition is going well and they should be on track to essentially terminate Family Health Plus by the end of the year.
NYS Veterans Homes
A new policy now requires that MCOs include one of the five New York State veterans homes in their network, if they are serving a county where one of these homes is located. While not mandated in statute, this decision represents a general agreement between the administration and all stakeholders. The five homes are located in Oxford, St. Albans, Batavia, Montrose and Long Island. Recent legislation passed by both houses of the Legislature, but not yet signed by the Governor, would exempt from veterans residing in veterans homes or attending veterans home adult day health care programs
New Contract Language
The model contract language now reflects additional provisions for vulnerable populations entitled: “Enhancements for Special Populations.” This includes additional changes in the mainstream contracting language. Plans should carefully review notices of the language changes and ensure that they are included in their standard contracts.
Part of the enhancements for special populations includes provision to make it easier for these individuals to navigate the grievance procedure. Intake workers are now required to end all calls with the question: “Have all your concerns been addressed?” and to provide the option of filing a grievance for any outstanding issues.
The model fair hearing notices are being consolidated into a single document to be used for both initial and final processing. The new model includes a notice that aid is to continue until such time as the fair hearing process is resolved. Recent statutory language included in the 2014-15 state budget changes the requirement from aid continuing until the current authorization period ends to aid continuing until the fair hearing process is resolved. Anyone filing a fair hearing request will receive an evidence package within 10 to 15 days. This change should also be reflected in new contract language.
DOH believes that the most expeditious means for a member to handle a grievance is through the plan’s internal process. The option to use either the plan’s internal grievance procedure or the fair hearing process is up to the individual, and in fact an individual can opt to do both simultaneously. There is also a third external review process for members who have exhausted the other two and still feel that the issue remains unresolved.
A new Appendix F now defines long term services and supports. This provision also requires that plans have in place person-centered care planning and that individuals be directed to other waiver services as deemed appropriate, e.g., the traumatic brain injury or consumer directed waiver programs.
New language in contracts mandates that members receive 10 days notice before any reduction or termination of services, regardless of any set authorization expirations.
Based upon plan input from an April plan meeting, adjustments have been made to accommodate the special needs of medically-fragile children. Plans discussed their best practices in this area and concluded that it is critical that this population not be evaluated using adult criteria. Contract language must now reflect the need to provide for normal growth and development in children, along with special behavioral health issues. The new language is based on recommendations from the American Academy of Pediatrics. The risk adjusted rate methodology should allow for rate adjustments for this population.
OPWDD and DISCOs
Under the People First Waiver, the Office for People with Developmental Disabilities (OPWDD) is developing a new 1115 waiver program to be managed by the Developmental Disability Individual Support and Care Coordination Organizations (DISCOs). OPWDD anticipates going live with the DISCOs on Oct. 1, 2014. Eligible individuals will be enrolled initially on a voluntary basis, with mandatory enrollment slated for Oct. 1, 2015.
OPWDD is currently working with the enrollment broker on educational and outreach programs. It is also developing a new information management system for the program that includes a care coordination dictionary. Care planning will be led by the specific discipline most suited to the individual’s needs, and the dictionary would form the basis for developing electronic service plans.
Based on core elements mandated by CMS, OPWDD is developing network standards and an advisory panel comprised of independent stakeholder advocates.
School-Based Health Centers
July 2015 is the new deadline for impacted MCOs to have contracts in place with school-based health centers. The contracts must include access to emergency services. There are currently approximately 55 sponsors operating 250 such centers.
Public Comments
The committee opened the floor to public comments. The Legal Aid Society expressed its support for the new protections afforded to vulnerable populations, in particular the notice to plans to respond to fair hearing requests within 10 days. For long term services and supports, DOH commented that it is in the process of developing new contract language which it expects to have out to the plans for comment shortly.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827