Managed Care Policy and Planning Meeting

The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on May 15 in Albany. For member convenience, we have posted all of the reference materials from the meeting as on our website as follows:

General Discussion

DOH opened the meeting with a discussion of bariatric issues and coverage, noting that at this time there are no specific bariatric care guidelines that managed care organizations are required to meet. However, the issue is under review. Plans in attendance raised concerns over the current billing cycle. DOH noted that there are a large number of rates in the pipeline and the April 2014 rate update is due out in July (see rates below).

The bifurcation of HARP HIV special needs plan rates is set to go live on Jan. 1, 2015 with an opportunity to further revise and adjust the rates. The discussion of a possible risk corridor is ongoing, with DOH hoping to have a webinar on the new rates.

As detailed in the April meeting, DOH once again stressed that with base year updates, the system is less dependent on FFS rates to calculate current premiums. They anticipate being able to move to a 24 month base period in the near future, which they believe will further increase the reliability of the rate setting data.

Plans that were required to file marketing plans are reminded that all marketing materials are due for submission by June 19.

Plans noted that there continues to be discrepancies between their 834 data and the eMedNY website. DOH acknowledged the problem and indicated that they are looking into the issue.

Highlights of the main agenda topics include:

Nursing Home Transition – DOH stated that June 1 is still the working date for the transition of new nursing home admissions into managed care for New York City (including Westchester and Long Island), with the rest of the State to follow six months later on Dec. 1. DOH acknowledged that there is still a possibility of the date being pushed back as they still await Centers for Medicare and Medicaid Services (CMS) approval. DOH had responded to the most recent round of follow-up questions from CMS and they are hopeful that final CMS approval will come in time to avoid having to push back the June 1 date.

Basic Health Plan (BHP) - DOH stated that they are moving forward with BHP implementation, with a plan solicitation to go out sometime next year and actual implementation slated for 2016. In advance of the 2016 implementation, DOH would seek to begin the transition of the Aliessa (i.e., lawfully-present immigrants with an immigration status that renders them ineligible for federal financial participation) population to BHP. Currently, there is no distinct MMCOR data for the Aliessa population, but DOH is seeking to develop this data base. Aliessa immigrants using long term care services would remain in Medicaid and would not be transferred to the BHP. Those recipients enrolled in Medicare will remain so and will not be transitioned. All of this is still subject to CMS approval.

Health Exchange Auto-Assignment – DOH acknowledged that there has been a problem with the auto-assignment algorithm currently in place for the New York State of Health exchange. The problem has resulted in some plans receiving too many auto-assignments while others plans were short-changed. There will be a temporary hold on auto-assignments under the exchange only as they seek to balance the system, with plans that have been short-changed likely to receive an influx of assignments.

FIDA - DOH has “re-tooled” the FIDA IDT policy and stated that providers should be pleased with the revisions. The revised policy is due out shortly and they are looking for additional comments. (It was released after the meeting.) The three-way draft contract was shared with FIDA plans, and DOH has scheduled calls to discuss/clarify information based on comments. Final contracts to plans are due out mid-June with a July 7 return date.

MLTC Rates - There are 16 outstanding MLTC Medicaid rate packages. Payment of 4/1/14 rates with wage parity adjustment is expected in mid-June (plans have rate sheets). DOH is willing to take plans experiencing cash flow issues off the two week lag. The process will be designed to grant reasonable requests quickly. The bulk of the rate updates involve paying the mandatory enrollee rate reconciliation.

The slides linked above provide tables of the five pools.

Quality Pool. $7.5M for 2013-14 pay for reporting model. $65M in 2014-15 funded by reductions to administrative component ($231 to $215 PMPM) and surplus from 3 percent to 1 percent.
QIVAP Pool. $70M for one year (2014 FY) paid as a retroactive lump sum for NYC plans only as pass through money for wage parity. Funded by 2 percent restoration, $20M VAP funds, and managed care efficiencies adjustments. DOH will distribute information to all NYC plans on how to apply.
High Price Nursing Home Mitigation Pool. $10M statewide funded by a 5 percent withhold of the NH COMPONENT OF THE PREMIUM ONLY. There is no definition yet of what high cost means. DOH reiterated that CMS is not willing to entertain discussion of a distinct rate cell. DOH is still open to discussing a corridor approach and willing to take a look at Florida model.
High Need Risk Pool. This is a single year statewide $100M pool funded by 2 percent withhold for PACE and Medicaid-only plans. The concept is to target those plans with a disproportionate number of 12/24 and vent patients by distributing part of the pool based on SAAM and survey data, and the remainder based on improved encounter data (see below).
BIP Pool. $50M to non-FIDA region Medicaid plans of all kinds including mainstream plans. There would be retroactive rate adjustments for plans that divert enrollees from out of institutional care. This is projected to last 14 months starting 1/1/14.

Encounter Data: DOH is seeking stricter enforcement of encounter data reporting. DOH monitors encounter reporting and data mines for anomalies. When found, plans are contacted. Plans can access reports on the HCS showing their encounter reporting key statistics as compared to other plans. There are separate reports for mainstream and MLTC plans. Model contracts will soon incorporate sanctions for failing to submit or failing to correct encounter data.

For more details on the meeting, please refer to the DOH references linked above.

Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827