DOH and CMS Update Plans on FIDA Rates
Following is a detailed summary of the joint Department of Health (DOH) and Centers for Medicare and Medicaid Services (CMS) June 26, 2014 Fully Integrated Duals Advantage (FIDA) Rate teleconference. The one handout for the call is the updated FIDA Demonstration Questions and Answers – please click here.
Quality Pool vs. Quality Withhold
The Quality Withhold on the Medicare and Medicaid components of the rate is slated to be phased in as follows:
- 2015 @ 1 percent
- 2016 @ 2 percent
- 2017 @ 3 percent
The withhold percentage is returned to plans based on performance measures. The current Managed Long Term Care (MLTC) quality pool will not directly transition into the FIDA, but will be accounted for through the withhold. Performance measures between the current MLTC program and FIDA will differ slightly, but overall should be fairly consistent.
Medicare Rate Component
CMS reported that current draft rates for the Medicare Parts A and B component of the FIDA rate remain essentially unchanged from those published on Nov. 8, 2013. These rates are still considered to be in draft form and are yet to be finalized. The rates represent a combination of current Fee-For-Service (FFS) and Medicare Advantage (MA) rates assuming a 1.0 percent savings rate.
One critical addition to the rate calculation will be the incorporation of a frailty factor for rates starting in 2015 (not in the current draft rates). The frailty factor is a multiplier to the base rates that increases based on the individual's level of difficulty in managing the Activities of Daily Living (ADLs). It is derived from the measures currently applied to Program for All-inclusive Care for the Elderly (PACE) and Fully Integrated Dual Eligibles – Special Needs Plans (FIDE-SNP). DOH and CMS anticipate that a large percentage of the FIDA population will be clinically nursing home eligible. Thus the assumption is that the frailty factor will generally be greater than zero, resulting in a positive adjustment to the base rates. However, the frailty adjustment can move in both directions and also result in a decrease in the base rates.
The frailty factor will be applied on a county-wide basis and will not be plan-specific. In other words, all plans in a given geographic area will receive the same adjustment, based on the average for that county.
Projected Enrollment
Both CMS and DOH continue to project enrollment based on the current population of dual eligibles and the percentage of that population that falls into qualifying categories. The assumption is that current enrollment projections will hold steady, unless anomalies arise in enrollment patterns or there are changes in eligibility.The trends in this area will be carefully monitored and any necessary adjustments will be done on a prospective basis only; prior period rates will not be adjusted.
Medicaid Rate Trend Factor
The final Medicaid capitation rate trend factor is due out during the week of June 30 and should mirror the information issued in the Nov. 8, 2013 report. DOH stated that FIDA trends will, to the extent possible, follow in line with MLTC rates; this includes both trend factors and wage parity. DOH sees both the trend and wage parity as closely tied and moving together.
Also closely tied to MLTC rates are the FIDA cost factors for care management, administration and medical costs associated with the Interdisciplinary Team (IDT) process. Overall costs under FIDA should be consistent with MLTC absent the demonstration program, and this is reflected in the current draft FIDA rates. A recurring theme during the call was the fact that CMS sees FIDA rates as being comparable to current Medicare FFS and MLTC capitation rates and that any significant deviation would be seen as problematic and needing correction.
Behavioral Health
Medicaid coverage for behavioral services is incorporated in the capitation rates with no major revisions anticipated. Eligible populations have been identified and costs have been extrapolated from the FFS rates with necessary adjustments. Most services under behavioral health would fall under Medicaid. Where appropriate, adjustments have been made to coordinate the Medicare and Medicaid pieces. Otherwise, the behavioral health piece is built into the capitation rate as would any other non-MLTC cost.
Recent expanded coverage for heroin addiction services are not reflected in the rates as this legislation was only recently passed. It is too soon to determine if and how rates would be adjusted to reflect the new mandate.
Public Discussion
As funding pools are developed under MLTC, e.g., the nursing home quality and “high-cost-high-needs” pools, it is unclear how this will translate into the FIDA rates as any deviations from the Memorandum of Understanding (MOU) would need to be approved by CMS. This is currently under discussion between DOH and CMS.
The high-costs-high-needs pool dollars that would be incorporated in FIDA rates would be limited to long term care services covered under MLTC, as hospital and acute care services have been covered under Medicare and would be reflected in the Medicare Part A/B component of the FIDA rate.
Specific rate reports for both Medicare Parts A/B and Medicaid are due out shortly, hopefully before the July 4 holiday. Since the nursing home transition has not yet been approved by CMS, it is unclear as to exactly how the nursing home costs will impact final rates for 2015.
As noted above, the MLTC quality pool does not have to be transitioned into the FIDA rates as this is accounted for in the quality withhold payment percentages. The sense is that the dollar amounts between the pool and the withhold are comparable.
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827