Managed Care Policy and Planning Meeting
The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Sept. 10th in Albany. For member convenience, we have posted all of the reference materials from the meeting as on our website as follows:
September 2015 Finance and Rate Development
September 2015 834 Information
September 2015 Basic Health Program/Essential Plan
September 2015 FIDA and MLTC Update
September 2015 Behavioral Health Transition
September 2015 Integrated Clinics
General Information
· Assistance for the Commonwealth of Puerto Rico
New York State Medicaid director, Jason Helgerson, opened the meeting with some general program updates. New York is now embarked on an action plan to assist the Commonwealth of Puerto Rico through its current financial crisis. The Puerto Rican debt crisis stems from approximately $70 billion owed by the government, whose credit rating currently stands at a non-investment grade level. The Cuomo administration’s assistance includes advice on restructuring their Medicaid program.
Director Helgerson was part of the Governor’s delegation that recently travelled to the Commonwealth. According to the Governor’s action plan, “Nearly 68 percent of the residents of Puerto Rico receive their health care through Medicare, Medicare Advantage or Medicaid. Unfortunately for the Puerto Rican government, federal funding formulas for these three programs are dramatically less favorable to Puerto Rico than they are for the 50 states.” The situation is made worse by the fact that the residents of Puerto Rico are not eligible for subsidies on the federal health insurance exchange, making commercial health insurance coverage unaffordable for many. Without some immediate restructuring up to one million Puerto Ricans stand to lose health insurance coverage. The current system includes almost universal managed care coverage.
· All Payer Data Base
The Department of Health, reminded the managed care organizations (the plans) of the need to be certified with the Medicaid All Payer Database (APD). The APD is a central clearinghouse for Medicaid claims data and will provide detailed information on Medicaid expenditures for a variety of stakeholders. All plans were due to be certified by Sept. 14th, but DOH reports that some plans are still not certified. For those plans that have not certified, DOH is granting an extension allowing plans to confirm that they will be certified by Oct. 12th.
· Emergency Plans
DOH is also asking plans to review their emergency preparedness plans. Plans should ensure that DOH has a minimum of two contacts during emergency operations. Emergency plans should include that home care services are supported; that authorizations and other administrative procedures can be temporarily relaxed; and that plans are prepared to add hours or personnel to manage the situation.
Behavioral Health and HARP
DOH commented on the transition of behavioral health (BH) services to managed care. They will be releasing a policy document on the transition, similar to that covering the nursing home transition. Plans will have an opportunity to comment on the policy document. DOH also released a July 2015 Special Edition of the Medicaid Update that details the transition and posted the billing manual on the Office of Mental Health website. The current transition timeline as posted includes:
· New York City Implementation
July 2015 - First Phase of HARP Enrollment Letters Distributed.
Enrollment notices issued to eligible individuals by NY Medicaid Choice in three phases:
- Approximately 20,000 issued in July/August for October 1, 2015 enrollment
- Approximately 20,000 issued in August/September for November 1, 2015 enrollment
- Approximately 20,000 issued in September/October for December 1, 2015 enrollment
October 1, 2015 Medicaid Managed Care plans and HARPs implement expansion of non-HCBS behavioral health services for enrolled members.
October 2015-January 2016 - HARP enrollment begins to phase in.
January 1, 2016 - HCBS become available for HARP eligible individuals.
DOH also reminded plans that contracts may need to be revised in order to reflect changes being made to the Model Contract.
The September 2015 Behavioral Health Transition slides include the latest Health and Recovery Plan (HARP) enrollment data and a link to Frequently Asked Questions (FAQs) on the rest of state transition. DOH is considering a contingency plan in the event that final Centers for Medicare and Medicaid Services (CMS) is not received this month. CMS is still reviewing HARP rates that DOH submitted 7/8/15 (see details from the September 2015 Finance and Rate Development). DOH is also concerned that not all plans have completed the claims testing process, which could result in claims processing problems come October.
Plans raised concern with the adequacy of the 3 percent pass-through to cover administrative expenses related to Health Home payments. The concern is that added administrative and oversight requirements are not adequately covered by the 3 percent. Based on actuarial modeling DOH believes the current rates are sufficient.
DSRIP and Value Based Payment
On the Delivery System Reform Incentive Payment (DSRIP) Program front, DOH reported that all the Performing Provider System (PPS) implementation plans are looking good and the PPSs should be in a good position to move forward with these plans. Upcoming discussions, including the Sept. 17th-18th conference (see below), will focus on value based payments (VBP).
DOH completed a new data run on PPS attributions and the goal is to provide each plan with their respective member PPS coverage.
The VBP work groups have been meeting and there has been strong participation. DOH noted that important clinical insights are emerging from the process and noted the analysis done on myocardial infarctions. DOH hopes to make the clinical data available to the plans. The process is intensive and requiring significant resources, but DOH believes they are already seeing some positive effects.
DOH is finalizing their Medicaid/Medicare alignment white paper to be submitted to CMS. They are now seeking to incorporate stakeholder comments. CMS is using New York’s VBP Roadmap as a model for other states to follow. The final paper will be put out to the plans before submission to CMS. In the case of special pilot projects, DOH is evaluating these on an individual basis and will reach out to plans for their input.
During last month’s meeting, DOH presented detailed slides on the VBP Quality Incentive Program (QIP), August 2015 Rates and Value Based Payment Guidance. DOH is planning a follow-up webinar (Sept. 30th) and is looking towards a strong alignment between the PPSs and plans. Approval letters that include verification of the 5 percent administrative add-on are out, and plans will need to coordinate with lead organizations for the processing of payments. Plans noted that in cases where there are only a small number of transactions the 5 percent add-on will not be sufficient to cover costs.
Please see the rate package slides for more details. Plans raised concern over the backlog in the approval of rate packages, noting that this is having serious cash flow implications for plans. DOH noted that most of the problem stems from delays in CMS approvals, and plans could engage in direct advocacy with CMS to encourage quicker action on the outstanding approvals. The plans also noted that the backlog of rate packages will create problems with year- end reporting.
IPRO is now in the process of auditing the final Quality Incentive /Vital Access Provider Pool (QIVAPP) awards, prior to submission to CMS for final approval. DOH is currently evaluating the program to determine if there will be an additional phase.
As listed in the slides, Phase I and II MLTC rates are in process and include the nursing home blend, effective April 2015.
The Phase III MLTC rate update will include the nursing home high cost mitigation pool effective retroactive to July 1, 2015. The pool is designed to reimburse plans for contracting with high cost nursing homes.
DOH also indicated that they will be performing federally mandated tax reconciliations over the next few weeks on mainstream plans that will result in retroactive adjustments to the April 2014 - March 2015 rates for any impacted plans.
Bill Emery from the Health Exchange reported that they continue to work on issues related to discrepancies between plans, eMedNY and the Health Exchange. They noted the following causes of such discrepancies:
- Late renewals
- Inaccurate XT transactions
- Failure to Process 834
- Not knowing Renewal Date
- Open Cases
- Duplicate accounts
- Failure to submit effectuations
- Restacking Issues with eMedNY
They have been working to clear up problem issues, and noted that in cases where a re-determination is needed and more than 90 days have passed members will be re-assigned to the same plan. 834 notices not received before the first of the month could result in a month of fee-for-service coverage, in which case there would be an 11 month window for the next renewal. Effective May 5th, all transactions now include the member’s eligibility end date to assist plans in better tracking the need for 834 submissions. The Exchange has also added a new XT modifier.
DOH reported that as of Sept. 1, 2015 the Fully Integrated Duals Advantage (FIDA) enrollment numbers were as follows:
FIDA Enrollment Update – Sept. 1, 2015
FIDA Enrollment NY Medicaid Choice Calls Received Total Opt-Outs
7,280 96,976 57,375
You may compare these numbers with last month’s statistics:
FIDA Enrollment Update – Aug. 1, 2015
FIDA Enrollment NY Medicaid Choice Calls Received Total Opt-Outs
7,676 96,976 54,287
According to these statistics FIDA enrollment has actually decreased. It is unclear as to why the statistic on calls received is unchanged. DOH is continuing to evaluate measures to increase FIDA enrollments and is seeking CMS approval for additional phase in of passive enrollments in 2016, likely starting in February of next year.
Since last month’s meeting, DOH provided the following updates:
All calendar year 2016 marketing materials have been released;
Plans submitted their 2016 marketing plan for review on August 31, 2015;
DOH hosted a FIDA overview and update webinar with over 540 individuals registered for the webinar; and DOH and CMS will host two FIDA provider events this month, on September 17 and 30th. Providers will be able to receive continuing education credits. In addition to DOH and CMS, the session will include the Medical Directors from AlphaCare Signature FIDA Plan and VNSNY Choice FIDA Complete who will discuss their best practices and experiences with the program.
The Managed Long Term Care (MLTC) enrollment numbers reported for August showed a slight increase in the number of total enrollees statewide from 146,154 reported last month to 147,588 enrollees. This numbers break down as follows:
- Partially Capitated (MLTC) 128,298
- Medicaid Advantage Plus (MAP) 6,098
- FIDA 7,676
- Program of All-Inclusive Care for the Elderly (PACE) 5,516
It should be noted that the August numbers for MLTC and MAP show a slight decrease from July (MLTC – 128,765 and MAP – 6,148).
Mandatory Medicaid enrollment is now in effect statewide, with a total of 66 plans comprised of 18 FIDA, 8 MAP, 8 PACE and 32 single cap MLTCs representing the bulk of enrollments as noted above. The July numbers listed a total of 69 plans, the decrease attributable to the loss of 3 FIDA plans.
DOH has released the following updates on MLTC:
MLTC Policy 13.18(a): Update MLTC Guidance on Hospice Coverage;
The Office of Health Insurance Programs (OHIP) will be hosting a Sept. 29th Long Term Care Forum from 10 a.m. – 1 p.m. at the New York Academy of Medicine located at 1216 Fifth Avenue, NY, NY 10029. The session is open to healthcare plans, providers, advocacy organizations, and other interested stakeholders. OHIP will be releasing registration information.
Basic Health Program/Essential Plan
In addition to the rate package schedule included in the slide presentation, DOH also provided guidance on Essential Plan Emergency (EHP) Out-of-Network Guidance. For Aliessa members, the health plan is required to pay the Medicaid default rate as now applies for such members. For non?Aliessa members, the Affordable Care Act (ACA) establishes minimum reimbursement amounts that health plans must pay for out?of?network (OON) emergency services. Essential Plan (EP) enrollees should have no liability for charges in excess of any applicable in?network cost sharing. DOH noted that patterns of reimbursement or billing for emergency services received by EP enrollees that hospitals and/or insurers believe to be unreasonable should be brought to their attention.
There is also a draft proposal designed to track member pregnancies for the purpose of creating an expedited transition to Medicaid. Currently, pregnant women are not eligible for enrollment in the EHP and their maternity services are not covered. Plans may need to revise their coverage policies for prenatal care once a mechanism is in place to identify pregnancies.
The day’s meeting ended with a presentation on Integrated Clinics pilot program. This was a follow up presentation to one delivered in an earlier Policy and Planning meeting. This is a relatively small program recently authorized in the 2012-13 NYS Budget (Chapter 56 of the Laws of 2012 (Part L)). Under this program providers are eligible for a streamlined approval and oversight process for clinics whose scope of service falls under more than one state agency (providers must possess at least two of the following licenses: Article 28, 31, and/or 32). There are currently 7 participating providers in 13 locations. The attached slides provide guidance on how managed care organizations are required to pay participating providers, including a 5 percent rate enhancement (see slide 8-12).
Contact: Patrick Cucinelli, pcucinelli@leadingageny.org, 518-867-8827