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Highlights of June Managed Care Policy & Planning Meeting

New populations and services that have been brought into the Managed Long Term Care (MLTC) benefit package, and those that will be included in the future, featured prominently in MLTC discussions at the June Managed Care Policy and Planning meeting. Highlights of the meeting are presented below.

MLTC Rates

DOH and Mercer are in the process of several MLTC rate calculation changes. For the 2016-17 rate year, the geographic factors that have been used to adjust consolidated three-region base costs to set rates for regions 2, 3 and 4 are being re-evaluated and may be replaced with regionally-specific base cost calculations as well as regional risk scores. The impact is not yet clear and DOH promised to provide more information as it becomes available. In a subsequent meeting with LeadingAge NY, plan members indicated that budget neutrality requirements make it unlikely that moving away from geographic factors would increase overall reimbursement but may help address what plans identify as unsustainably low rates in region 4.  

There is also a change in how the rates will be adjusted to reflect the nursing home population. At this time, plans report nursing home days and DOH uses them to update the nursing home rate add-on quarterly. For 2016-17, the state will project utilization to set the rate for a full 12 months. Responding to concerns, DOH indicated that they would monitor plan enrollee nursing home utilization and address the issues if actual experience diverges significantly from projections. DOH confirmed that the high cost nursing home pool designed to reimburse plans that contract with nursing homes whose benchmark rate is above average will be closer to $4-5 million in 2015-16 than the $10 million originally envisioned.

In response to a question about extending the requirement for plans to pay nursing home benchmark rates for longer than the current three-year time frame, DOH indicated that while they had not had discussions on it yet, the state would not be opposed to such a discussion, and suggested that the state may seek to link value-based payment provisions to any such extension.    

The state will not withhold premiums during the course of the year to fund pools aimed to address high cost community enrollees and the use of high cost nursing homes. Instead, the reconciliation for these pools will be done retrospectively, with pool funds being collected at the same time as they are distributed. While this approach will help maintain cash flow, plans will need to be aware of potential recoupments if their pool contributions exceed their pool distributions. In a subsequent conversation, DOH clarified that the state is not able to follow this model with the quality pool, which will continue to be funded by premium withholds during the course of the year.

Medicaid Loss Ratio (MLR)

DOH indicated that the state would work with plans and their representatives on defining the MLR calculation during the summer and convened a meeting later in June to begin the work. At the subsequent MLR meeting, DOH indicated that the state’s approach would primarily follow new federal regulations (i.e., "mega-reg”) governing MLR for Medicaid managed care, that the MLR would apply to all plan types including MLTC and that a managed care organization's products could be aggregated when determining compliance.   

Care management, quality improvement and fraud prevention costs would be in the numerator when the calculation was done.  While DOH was leaning toward setting the MLR at 88 percent with the excess amount recouped and reinvested into quality payments, no final decisions were made on the threshold. In a conversation with LeadingAge NY, DOH indicated that it did not intend to apply an MLR to MLTC plans for the 2016-17 state fiscal year. 

Community First Choice Option (CFCO)

The DOH mention that they were contemplating including CFCO services in MLTC sooner than the previously indicated July 2017 date sparked concern among some plans. CFCO incorporates enhanced personal attendant services and supports into the Medicaid State Plan for eligible individuals who need help with everyday activities due to a physical, developmental or behavioral disability. 

Plans expressed concern that some of the services brought into MLTC as part of CFCO, such as supervision and cueing services, may garner significant demand. Participants suggested that the state make sure the addition of these services is done carefully enough to ensure that operational, eligibility and rate adjustment issues are adequately addressed. It was also pointed out that individuals receiving CFCO services may have an impact on plans' risk scores, which should be considered at the outset. DOH subsequently presented a detailed webinar on CFCO which will be posted on the University at Albany School of Public Health website here (slides are available now).

Transition of Waivers into Managed Care

DOH reminded attendees that an updated draft plan for transitioning Traumatic Brain Injury (TBI) and Nursing Home Transition and Diversion (NHTD) Waiver participants and services into managed care has been posted on the MRT 90 web page. The state recently presented a webinar on the updated plan that is posted here. The associated slides are here.

The transition is scheduled for January 2018 and DOH is collecting comments on the updated plan through Aug. 24th.

Other Updates

DOH also announced that they would be reconfiguring the monthly managed care policy and planning meetings starting in July with more targeted participation to ensure open and productive discussions between plans and the state. The new schedule will feature mainstream Medicaid managed care issues in the morning while the afternoon session would open with rate updates for both mainstream and MLTC plans.

LeadingAge NY and member plans had an opportunity to meet with DOH recently to discuss MLTC rate setting issues. Members reiterated concerns about the adequacy of rate adjustments to reflect new populations and services, especially the nursing home population; warned about the potential of a major impact on plans when new CFCO services are included in the benefit package; and suggested some issues to consider when calculating the MLR calculation and designing value-based payment structures. DOH staff were receptive and expressed their commitment to doing all they could to address the concerns.

We remind member plans that DOH issued their final proposed standard home care and Adult Day Health Care billing codes in mid-June requesting that plans notify DOH through their associations by June 30th if they identify any critical issues with the codes. While there is significant overlap with the DOH codes and those most plans currently use, please let us know ASAP if your organization would find it impossible to implement the codes within a reasonable timeframe or if you have other critical concerns before the state adopts them as final. 

Contact: Darius Kirstein, dkirstein@leadingageny.org, 518-867-8841