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Rate Issues, VBP, DSRIP Dashboards Discussed at May Plan Meeting

A significant portion of the May 2016 Managed Care Policy and Planning meeting was devoted to a discussion of mainstream Medicaid managed care premium development in which DOH outlined an overpayment issue and plan representatives expressed strong concerns regarding the adequacy of the pharmacy component of the premium. While the agenda promised a presentation by Mercer on the development of the nursing home transition rate, due to time constraints the topic was not addressed and will be covered via webinar to be arranged by The Department of Health (DOH). Issues of greatest interest to Managed Long Term Care (MLTC) plans and long term care providers are outlined below. Section titles link to associated handouts. 

MLTC/FIDA Program Updates

There are currently 65 actively enrolling managed long term care plans serving 165,612 individuals. The bulk of these, 148,786 enrollees, are in 31 Partially Capitated plans while the state’s nine Programs of All Inclusive Care for the Elderly (PACE) have 5,547 participants and seven Medicaid Advantage Plus (MAP) plans enroll 5,728. There are 5,490 individuals served by 17 Fully Integrated Dual Advantage (FIDA) plans and enrollment in the specialized FIDA-IDD plan serving individuals with developmental disabilities that began operating this year stands at 61. The Conflict Free Evaluation and Enrollment Center (CFEEC) averages 833 calls per day, employs 148 nurses and has conducted almost 77,000 evaluations to date with a 98% approval rate.

In moving towards implementing the Community First Choice Option (CFCO), DOH is finalizing guidance for local social services districts that will help them understand their roles and responsibilities and how CFCO services and supports will be accessed and authorized. The state has previously indicated that CFCO services would first be available to Medicaid fee-for-service recipients and subsequently brought into the MLTC benefit package and DOH is now beginning discussions on bringing these services into MLTC. These are enhanced personal attendant services and supports geared to assist individuals eligible for institutional level of care due to physical, developmental or behavioral disability to live and receive services in the community.    

DOH reviewed two recently released documents: a Dear Administrator Letter differentiating between licensed and unlicensed housing settings and a Dear Health Plan Letter clarifying the transition process between a mainstream Medicaid managed care plan and an MLTC plan. The guidance makes no change to the policy, just provides clarification. Meeting participants expressed concern that the most recently proposed MLTC contract revisions seem inconsistent with this guidance; DOH instructed that the guidance in the letter should govern.

FIDA plans were reminded that they may begin submitting U files on May 23rd and the 2017 benefit packages sent to plans are due back to DOH on June 6th.         

Rate Setting Priorities

The state’s 2016-17 rate setting priorities for MLTC include reflecting the impact of provisions enacted in the state budget; the nursing home transition add-on; Fair Labor Standards Act (FLSA) provisions and the minimum wage increase; regional geographic adjustment to the rate; Value Based Payment (VBP); and compliance with the new CMS Medicaid Managed Care “Mega-Rule”. The list of rate setting priorities for mainstream plans include pharmacy component update, shift of behavioral health populations to HARP and the administrative component methodology.   

DOH intends to convene a workgroup on meeting federal Medical Loss Ratio requirements and address other issues that the federal Medicaid Managed Care rule raises. As part of implementing encounter reporting penalty provisions contained in the state budget, DOH will continue to provide the validation reports currently provided and will share additional plan-specific reports to allow plans to gauge their performance. DOH is planning a webinar at the end of May.  

Value Based Payment (VBP)

Marc Berg of KPMG, the state’s contractor for VBP implementation, provided an update on VBP activities and the status of VBP pilots. As the initial pilots are being launched, baseline survey data indicates that 27-28 percent of current spending involves level 1-3 VBP arrangements and 7 percent qualifies as level 0. Most of the Clinical Advisory Groups have completed their work and have submitted reports that recommend VBP measures that align closely with current QUARR measures while adding some key outcome measures. The reports will eventually be posted to the DSRIP VBP website. 

While the state encourages all pilots, based on allocated funding it expects to be able to provide administrative support for about 15 initiatives in 2016, which are mostly mainstream managed care plan oriented and currently exclude dual eligible enrollees. There is no formal application process and pilots will be selected on a first come first served basis although geographical reach and variety of payment arrangements will be considered in the selection process. Plans will receive quarterly performance reports with their key metrics. MLTC pilots are not slated to begin until late 2016 and 2017.  

DOH is finishing an update to the state’s VBP roadmap and will be sponsoring VBP bootcamps beginning in early June. This regional training is meant for all plans, providers and stakeholders and will be based in five regions with three sessions contemplated for each region. The first event is scheduled June 2nd for the Capital/Southern Tier/Mid-Hudson region. More information on the bootcamps is available here.     

DSRIP Dashboard

Staff from Salient, the state’s contractor that provides the interface with the Medicaid data warehouse, provided a demonstration of the DSRIP performance dashboard that all plans will have access to shortly. The dashboard will allow plans to filter data for individuals attributed to a DSRIP project by plan and product line to be able to drill down into their enrollee data. The goal is to use the dashboard to support PPS performance improvement. While Medicare data is not currently in the system, Salient is working to incorporate it. Plans will be receiving a data use agreement and instructions on accessing the dashboard within two weeks.   


The New York Association on Independent Living presented on their Open Doors Transition Center Project that aims to identify individuals in institutional settings that are interested in living in the community and assisting them in meeting this goal. The project is supported by federal Money Follows the Person (MFP) funding and staffed by a regional structure of transition specialists statewide. The association is interested in working with MLTC plans to assist with transition services such as outreach, resolving barriers, community preparedness education, peer-to-peer support networks and follow-up. 

In preparation of the July 1, 2016 carve-in of behavioral health services outside of New York City, DOH is reminding plans to complete their claims testing by Sep. 30th, review network adequacy requirements and continue with member services staff training. Regional planning consortium kick-off events start June 1st and will provide an overview of Medicaid Managed Care behavioral health changes, lessons from implementation of behavioral health in managed care in NYC, and information on available resources. The meeting schedule is available here.


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