Update-Managed Care Policy and Planning Meeting

The Department of Health (DOH) hosted their monthly Managed Care Policy and Planning Meeting on Thurs., March 12 in Albany. For member convenience, we have posted all of the reference materials from the meeting on our website as follows:

March 2015 Agenda

March 2015 Medicaid Analytics Performance Portal

March 2015 OPWDD Transition Update

March 2015 Mainstream and HIVSNP Rate Development

March 2015 MLTC and FIDA Update

March 2015 MMCOR and HIV SNPOR Changes

March 2015 Behavioral Health Update

Budget Update
Valencia Lloyd, director, Office of Health Insurance Programs, and John Ulberg, director, Division of Health Care Financing hosted the meeting. The discussion began with a review of State budget items relevant to managed care, focusing on four areas:

Supplemental Pharmacy Rebates and other Pharmacy Initiatives;
Prescriber Prevails;
Transportation Carve-Out for Managed Long Term Care (MLTC); and
Managed Care Cost Sharing.

Pharmacy Initiatives: DOH noted that both the Assembly and Senate rejected the Executive Budget proposal to authorize the Commissioner of Health to negotiate directly with pharmaceutical manufacturers for the provision of supplemental rebates, including utilization-based rebates for managed care enrollees. The legislative version would limit the rebate authorization to HIV/retroviral drugs only. Both houses also rejected the proposal to reimburse for Medicare Part B covered drugs at acquisition cost.

DOH reviewed their initiative to implement Diabetic Supply Efficiencies, in which they would seek to apply the current rebates available under Fee-for-Service (FFS) to managed care and adjust managed care rates accordingly.

A measure, which carries significant fiscal implications, is the rejection by both houses of the Executive Budget proposal to eliminate the ability of a prescribing professional to override the preferred drug program and obtain Medicaid coverage of a prescription drug that is not on the preferred drug list. In addition, the budget proposes to expand prior authorization under the Clinical Drug Review Program by allowing the Commissioner of Health to require prior authorization of any drug prior to receiving a recommendation by the Drug Utilization Review Board. There was significant discussion on the potential negative impact on current State budget projections and potential downside to plans if prescribers are allowed to override formularies especially when it comes to HIV/AIDS and new Hepatitis C drugs. This will be a serious issue of debate between the Executive and the Legislature.

DOH also sought plan input on how best to coordinate State-negotiated pharmacy rebates with those already negotiated by the plans on an individual basis, and how that should be reflected in rates. The consensus was that plans should continue to negotiate their own best deals, while DOH continues to pursue a global approach towards drug rebates.

Transportation Carve Out: The Executive Budget includes an administrative proposal to eliminate transportation from the MLTC benefit package and has attributed a $14.7 million savings to this action. The savings would grow to $29.4 million in SFY 2016-17. The savings would presumably be generated from reductions in MLTC premiums. DOH reviewed a recent call with MLTC plans in which they acknowledged concerns raised. They assured plans that the current Oct. 1, 2015 projected implementation date allows for adequate time to address concerns. They also acknowledged that the MLTC population has additional needs as compared to the mainstream populations that are currently served by a central transportation coordinator system.

Plans asked about coverage for transportation services that are not medical in nature. DOH responded that all services covered under Medicaid will continue to be covered, and they are open to further discussion on any additional transportation services that need to be included for the MLTC population.

Please note that LeadingAge NY has brought language to the Legislature to be included in a final budget agreement, and is in opposition to this initiative that is included in the Senate budget bill. In separate discussions with DOH, LeadingAge NY confirmed that MAP, Fully Integrated Duals Advantage (FIDA) and PACE programs are not impacted by this carve out.

Managed Care Cost Sharing: Under pressure from the Centers for Medicare and Medicaid Services (CMS), DOH is moving forward with requiring plans to collect co-pay amounts and deducting those amounts from the plan rates. DOH needs to research the source of the CMS mandate and confirm that this is indeed a requirement under the Affordable Care Act. The ultimate goal would be to align managed care policy and rates with the current FFS system, including allowing provisions for excluded populations and any ceiling limitations on beneficiary liability. DOH is not supportive of this initiative and is seeking to clarify the authority under which CMS is enforcing the measure and DOH may also seek a waiver from the requirement. DOH confirmed that nursing home Net Applied Monthly Income (NAMI) is not considered a co-pay and is unaffected by this issue.

Medicaid Analytics Performance Portal
DOH announced a revised “go live” date for health home data to be released on the Medicaid Analytics Performance Portal (MAPP). The MAPP is a performance management system designed to provide tools to the Health Home network and support the Health Home and Delivery System Reform Incentive Payment (DSRIP) program performance management technology needs. The linked presentation features samples of the dashboards and functionality of the MAPP tools.

OPWDD Transition Update
The presentation from the Office of Persons with Developmental Disabilities (OPWDD) focused on the theme of “care management for all” and the development of two models of care for the DD population. The more common model is the Developmental Disabilities Individual Support and Care Coordination Organization (DISCO). There is also one managed care plan that is seeking to develop a FIDA-based model for this population – the FIDA-IDD plan.

The FIDA-IDD plan will deliver integrated healthcare and long term care benefits to individuals with Medicare and Medicaid who reside in the targeted geographic area and who choose to participate in the Demonstration, and will include:

Target area - NYC, Nassau, Suffolk, Westchester, and Rockland;
FIDA will be available in all counties at once - no phased implementation;
Plan is responsible for coordination of all the individual’s services (Medicare, Medicaid, specialty OPWDD services, and any others required to meet the individual’s needs); and
Demonstration is currently scheduled to begin later in 2015 and continue through 2018.

No other state is implementing a FIDA-IDD plan.

The Certificate of Authority (COA) process is currently underway and is being integrated with the DISCO start-up grant approvals. Grant approvals are anticipated in the coming weeks, with a final timeline to be approved by the Commissioner’s Transformation Panel.

Mainstream and HIVSNP Rate Development
Mercer Representatives presented an extensive rate analysis with a focus on pharmaceutical issues. Mercer is seeking to build rates based on actual encounter data and individual plan experience.

For FY 2015–16 pharmacy premium development, methodology the updates include:

premiums developed on individual region basis;
for HIVSNP, separate development for TANF/SN Adult and TANF Children;
non-covered drugs removed from base;
addition of Clinical Edits Efficiency Adjustment; and
FHP Transition into TANF/SN Adult. All other elements of the methodology remain generally consistent with the FY 2014–15 methodology.

Other issues impacting the FY 2015-16 premium development include: wage parity, nursing home transition and Behavioral Health Plans (BHP)

Wage Parity: Based on the DOH and Department of Labor analysis, Mercer estimates the impact of the wage parity adjustment will result in an increase in regional average rates for personal care and home health serviced in the NYC Metro region. Limitations in the MMCOR reporting for personal care services Mercer leveraged the data from the MLTC operating report. Adjustments to reflect applicability only to Non-Consumer Directed Personal Care Services and the applicability only to Personal Care and Home Health Aide Services were considered.

Nursing Home Transition: Mercer received the final Jan. 1, 2015 Nursing Home benchmark rates and is consulting with DOH regarding subsequent benchmark rate updates throughout the year. Separate nursing home transition rates will be developed for mainstream and HIVSNP and will be provided as part of the FY 2015-16 April rate package retroactive to Feb. 1, 2015.

Basic Health Plans: Phase 1 of the implementation will begin April 1 and run through the end of the year including the Aliessa population. Actual rate development is consistent with the FY 2014-15 methodology. Phase 2 is set to begin Jan. 1, 2016 with a target population of that includes both the Aliessa and the non-Medicaid individuals up to 200 percent of the Federal Poverty Limit. Open issues include: source data for rate development; supplemental data needs for rate development adjustments; and rate cell structure.

MLTC and FIDA Update
DOH reported that the FIDA program is operational in New York City and Nassau County (Region I), while the roll-out to Region II (Suffolk and Westchester) is on hold due to the need to meet Medicare network adequacy. Until further notice plans may not market in Region II and may not accept opt-in enrollments. CMS and DOH will continue to review Medicare networks in Region II and plans will have until the end of April to re-submit the networks.

The first wave of Passive Enrollment for Region I will be effective April 1, 2015, for:

Non-Supplemental Security Income (SSI) individuals with an annual coverage authorization date between June and August 2015;
SSI individuals with a birthday between January and March; and
the 90-day, 60-day, and 30-day notices were mailed.

The second wave of Passive Enrollment in Region I will be effective May 1, 2015, for:

Non-SSI individuals with an annual coverage authorization date between September and November 2015;
SSI individuals that have a birthday between April and June;
the 90-day and the 60-day notices were released; and
the 30-day notice will be released on March 24-26.

DOH provided a FIDA enrollment update as of March 7 that projects enrollment of 8,667 as of May 1 with 38,801 opt-outs.

Provider outreach and communications remains a primary concern. The core provider training module on the Lewin portal is functional and more than 4,300 providers have registered for the training. DOH is advising that plans should be educating and communicating with provider community beyond the trainings on Lewin portal. DOH is also intending to develop additional steps to increase education and awareness.

To enhance marketing efforts, DOH is developing a MLTC/FIDA comparison chart for plans to use to explain benefits of FIDA. In addition, DOH is reviewing current Marketing rules to provide additional clarification based on plan questions.

MLTC enrollment remains stable at around 139,000. Counties left to complete the transition, upon approval by CMS, are the Southern Tier counties of Allegany, Chautauqua, Chemung, Schuyler, Seneca and Yates; and the North Country counties of Clinton, Essex, Franklin, Hamilton, Jefferson, Lewis and St. Lawrence.

DOH also reported that they are working with CMS to increase FIDA rates and reduce variations between the area specific rates and the overall rate.

Plans continue to express concern over the IDT process; DOH responded that they are continuing to explore ways to allow for greater flexibility.

Conflict Free Evaluation and Enrollment Center: DOH reported on Conflict-Free Evaluation and Enrollment Center (CFEEC) activity as of Jan. 31, 2015, including:

the CFEEC is operational in Bronx, Nassau, New York, Kings, Queens, Richmond, Suffolk and Westchester counties;
on March 1, 2015, CFEEC was implemented in Albany, Columbia, Dutchess, Erie, Fulton, Greene, Monroe, Montgomery, Onondaga, Orange, Putnam, Rensselaer, Rockland, Saratoga, Schenectady, Schoharie, Sullivan, Ulster, Warren and Washington counties; and
letters were sent to each Local Department of Social Services (LDSS) commissioner, explaining the changes and nurse trainings were completed in these counties.

Please refer to the linked presentation for more statistics. DOH noted that they are also developing additional statistics on the CFEEC performance that can be shared with plans. One additional statistics noted was that approximately 76 percent of referrals to the CFEEC end up signing up with the plan that originally referred the individual to the CFEEC.

MMCOR and HIV SNPOR Changes
DOH is currently in the process of developing MMCOR reporting revisions that include new HARP and Behavioral Health lines of service. The linked slides provide samples of the proposed revisions.

Behavioral Health/HARP Update
DOH is working with CMS to develop new services to be added to the BH 1115 waiver amendment (for Mainstream and HARP populations), including:

Community Mental Health Services
Licensed Behavioral Health Practitioner Services within an OMH licensed Part 599 clinic;
Allow for the provision of community based (offsite) mental health services; and
Behavioral Health Crisis Intervention to be moved from HCBS and allow for mobile crisis intervention.

The next steps include obtaining Special Terms and Conditions from CMS and receiving approval of capitated and non-risk rates.

DOH outlined the following Rest of State preliminary timeline:

Distribute ROS RFQ: End of March 2015
ROS RFQ Submissions due to NYS: Mid-June 2015
State review of RFQ: Mid-June- July 2015
Commissioner Sign Off of ROS designation: End of July 2015

DOH is creating a new HARP eligible list based on service use from July 2013 to June 2014, and a separate list run for calendar year 2014 to be distributed sometime in the next few days. For downstate, Maximus enrollment letters will be distributed in phases by birthdate and DOH is working with Mercer to identify mainstream rate implications.

Delivery System Reform Incentive Program (DSRIP)
All 25 DSRIP projects have been approved with passing scores. Current reviews are expected to have only minor impact on scores and no significant monetary impact. DOH anticipates final scores to be announced shortly. Final attributions will determine the allocations between private and public funding pools. DOH also anticipates at least one additional round to allow for providers who have not already done so to sign up with a PPS. The PPS organizations are currently now working on final implementation plans. Current analysis indicates that 75 percent of PPS plan assignments are driven by the individual’s Primary Care Provider. COPA applications have not been posted.

Value Based Purchasing (VBP)
DOH is currently working on continuing to revise its VBP “Roadmap”. Providers have consistently communicated the need for more flexibility, and DOH is seeking more specifics on how to continue to revise the Roadmap. CMS and other states are now looking at New York as a model for DSRIP development, including the development of VBP.

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