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OPWDD FIDA, Enacted State Budget Among Focus of Plan Meeting

During the April Medicaid Managed Care Policy and Planning Meeting held last week in Albany, participants heard about the state’s rate setting priorities, received updates on the recently enacted state budget and learned about a new Fully Integrated Duals Advantage (FIDA) plan serving individuals with developmental disabilities.    

Highlights of the meeting that may be of greatest interest to Managed Long Term Care (MLTC) stakeholders are outlined below. Section titles link to the applicable handout or slides.

MLTC Rate Status Update

The Department of Health (DOH) expects to have draft April 2015 Phase IV and Phase V rates for Partially Capitated plans completed by late April. Draft Medicaid Advantage and Medicaid Advantage Plus (MAP) Jan. 2014 rates are also slated to be done in April and DOH will present a webinar to review MAP rates. Draft April 2016 rates for Programs of All Inclusive Care for the Elderly (PACE) and Partially Capitated plans are expected in June. Going forward DOH intends to post the rate package schedule for all providers and plans on their website and will hold an encounter logic webinar which will address concerns on how personal care encounter data is being submitted.   

QIVAPP Reconciliation

DOH reviewed several Quality Incentive Vital Access Pool reconciliation scenarios. The reconciliation subtracts any payment made to agencies from the original $35M distribution from their final allocation of the total $70M QIVAPP funding that reflects IPRO review results. Agencies that received funding in the original distribution and were deemed ineligible by IPRO and those whose original funding exceeds their final allocation will be subject to recoupment. Those that did not receive funding from the original distribution or whose final allocation exceeds the original distribution will receive their final funding allocation, less any funding received in the original distribution. While no specific guidance was issued, DOH urged plans to be reasonable in making recoupments.      

In response to plan concerns, DOH agreed to notify those agencies that were disqualified by IPRO from receiving funding. DOH staff will be discussing QIVAPP's next steps shortly and request that plans submit their questions, such as what course of action should be followed in reconciling payments if a provider no longer exists, to the department this week.

Rate Setting Priorities

DOH provided a listing of their rate setting priorities for the state fiscal year. Impact of budget provisions top the list which also includes rate adjustments to reflect FLSA and minimum wage changes, value based payment pilots, compliance with forthcoming CMS managed care regulations and re-evaluation of the geographic adjustments used in MLTC. 

Enacted Budget Provisions

DOH budget review included the following updates:

  • 3.5 Percent Profit Cap - DOH will work with associations on establishing a Medical Loss Ratio to implement this provision and expect it to be informed by forthcoming guidance from CMS.
  • OSC Audit Findings - DOH expects to reduce plan premiums by $40M in response to the Office of State Controller (OSC) audit findings that plans should fund rate setting actuarial services and that the administrative component contained a double payment related to MTA taxes. The $20M related to the later issue will be a one-time impact, while the cost of actuarial services will be an ongoing $20M impact. DOH is examining their rate setting practices to anticipate OSC concerns and has been educating OSC staff about managed care rate setting. The change will be reflected in April 2016 rates.  
  • OMIG/Plan Medical Fiscal Integrity - DOH is working to incorporate this $30M reduction into April 2015 rates. The reduction will be applied to all lines of business based on revenue and then proportionalized to individual plans. 
  • Minimum Wage Adjustment - DOH will work with provider associations on sector-specific fiscal estimates of implementing the minimum wage increase. This funding will be distributed through the plans and is expected to be included in the Oct. 2016 rates. DOH expects that the high profile of this issue will help expedite CMS approval.
  • Encounter Reporting Penalties - DOH is working on guidance to plans on how timeliness, completeness and accuracy will be measured and will issue reports on performance to plans before beginning to assess penalties.     
  • Benefit Carve-in - DOH will convene a workgroup to work on incorporating all Medicaid benefits into the MLTC benefit package. The most significant additions include behavioral health, respite and Medicare co-payments for services not covered by the MLTC benefits package. DOH acknowledged that the move will have rate implications, but that they are early in the process and that plans should not yet make presumptions about network adequacy requirements based on this change. The effective date is Oct. 1, 2016 and requires federal approval, although there has been minimal discussions with CMS on this issue so far.


DOH has developed a multipronged FIDA advertising campaign that will include digital, print, outdoor and radio advertisements. Website and phone ap ads will begin appearing in late May. DOH urges plans to time their outreach activities to maximize the impact of the campaign. 

Total statewide enrollment stands at 162,719. Of these, 5,566 individuals are enrolled in FIDA, 5,661 in MAP and 5,508 participating in PACE. The Conflict Free Evaluation and Enrollment Center is averaging 854 calls per day and has conducted 71,776 evaluations to date with a 97% approval rate. DOH will collect PACE Model Expansion RFI comments until April 29th.

DOH has recently issued the following materials:

  • New FIDA FAQs on 1) HARP-like benefits, Health Homes, & Hospice and 2) FIDA Reforms are available here.
  • MLTC Policy 16.01 on UAS-NY Assessment Requirements and MLTC Policy 16.02 on Statutory Changes for Consumer Directed Personal Assistance Services (CDPAS) are posted here.
  • Statewide documents on MLTC Plan and Health Home Collaborations can be accessed here and the Money Follows the Person (MFP) Operational Protocol and Sustainability Plan are here.

Behavioral Health Update

The behavioral health transition for areas outside of New York City is moving ahead with a July 1, 2016 start date. Managed Care Organizations (MCO) have until May 1, 2016 to change Health and Recovery Plan (HARP) marketing names.  HARP-eligible Medicaid managed care enrollees of MCOs that operate HARP plans will be passively enrolled into that MCO’s HARP plan unless they elect to opt out during the 30-day opt-out period.  HARP-eligible enrollees of MCOs that do not operate a HARP plan will not be passively enrolled, but will be notified of the option to enroll into a HARP. 

The state reported that in New York City where the transition began last year, 84.3 percent of behavioral health claims were paid, 14.3 percent were denied, while 1.5 percent were pended. The largest plan that represented more than a third of all behavioral health claims in NYC had a paid claim rate of 87 percent.


A FIDA Plan serving individuals with developmental disabilities (FIDA-IDD) has begun enrollment in the seven county FIDA region as well as Rockland County. Partners Health Plan is the sole FIDA-IDD plan and the first in the nation to provide comprehensive care coordination for all Medicare and Medicaid services for the IDD population. Enrollment is voluntary with no passive enrollment and available now in all target counties. Informational mailings for the target population began in March, which are followed by full packets 15 days later. There are ongoing outreach activities; a list of informational sessions is posted here. The program requires that a performance measure payment plan be developed by summer and OPWDD is evaluating IDD specific quality measures.

A report from the transformation panel that was formed to address the future of the state’s systems of support for people with disabilities issued a report in Feb. which is available on the OPWDD web site.       

Other Issues

The state also provided a DSRIP update. Slides are available here. DOH ended their presentation with a request to plans that when submitting fair hearing materials they clearly indicate on the evidence packet cover letter whether it is being submitted by a mainstream or an MLTC plan.

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