Second MRT 2 Meeting Highlights Proposals Submitted to Curb Long-Term Care Spending
At the second meeting of the Medicaid Redesign Team (MRT) 2 on March 10th, members discussed the proposals submitted by stakeholders to fill the $2.5 billion budget gap, focusing on strategies to curb Managed Long Term Care (MLTC) enrollment and utilization of personal care and Consumer Directed Personal Assistance Services (CDPAS). The meeting also covered a broad range of proposals related to the Medicaid Global Cap, hospitals, care management, managed care, pharmacy, health information technology (IT), transportation, workforce, program integrity, and other health care sectors. MRT 2 members asked questions about the various proposals but did not reach any decisions in the meeting. Over the next several days, Department of Health (DOH) staff will develop a final set of recommendations to be presented to the MRT 2 for consideration and approval at the final meeting on March 19th. The meeting slides are available here; however, readers should understand that the proposals listed in the slides are merely under consideration and have not been approved by the MRT 2.
At the outset, DOH staff noted that the State Fiscal Year (SFY) 2019-20 cuts implemented in the current quarter will continue into the upcoming SFY. These include:
- Discontinuing Enhanced Safety Net Hospital Payments
- Delaying Enhanced Federal Medical Assistance Percentage (eFMAP) Reconciliation
- Discontinuing Delivery System Reform Incentive Payment (DSRIP) Equity Pools
- Discontinuing MLTC Quality Payments
- Discontinuing Value-Based Payment (VBP) Stimulus Payments
- MLTC Rate Range Reduction
- Medicaid Managed Care Rate Range Reduction
- Supportive Housing Payment Reduction
Among the many proposals discussed, the State noted a proposal to increase the 1 percent across-the-board (ATB) cut if necessary to achieve the $2.5 billion target.
The State received several different types of proposals governing the Global Cap. These included replacing the Consumer Price Index (CPI) as the standard for growth in the cap with a different metric and/or accommodating enrollment growth. In addition, proposals were submitted to modify the categories of spending covered by the Global Cap.
The MRT 2 discussed two categories of proposals pertaining to long-term care: (i) proposals unanimously supported by the Long-Term Care Advisory Group (LTCAG); and (ii) proposals submitted by stakeholders through the public process. The LTCAG has recommended approximately 30 proposals to be advanced to the full MRT 2 for its consideration which will be incorporated into a special report from the LTCAG, including:
- MLTC Restructuring: Limit the number and geographic area of MLTC plans and consolidate existing partial capitation plans and impose “reasonable limitations” on the number of integrated plans (i.e., Medicaid Advantage, Medicaid Advantage Plus (MAP), Programs of All-Inclusive Care for the Elderly (PACE)), while giving a preference for plans with experience in integrated options and the long-term care sector.
- MLTC Care Management Reform: Use a uniform tasking tool to inform the number of hours of services authorized, raise eligibility criteria for MLTC enrollment to require a need for assistance in at least two activities of daily living, and eliminate the requirement that MLTC plans make monthly care management calls.
- Fair Hearing Process Reforms: Require additional education for hearing officer, modify the appeals process to ensure exhaustion of internal appeals, and improve efficiencies through procedural and scheduling changes.
- Increase Enrollment in Integrated (Medicare/Medicaid) Plans: Implement default enrollment of mainstream managed care members who become Medicare-eligible and modify auto-assignment processes to favor integrated plans.
- Consumer Directed Personal Assistance Program (CDPAP) Reforms: Permit personal assistants to transport consumers to routine medical appointments; verify that individuals in CDPAP are self-directing; establish clear standards for responsibilities of consumers and designated representatives; and implement CDPAP conflict of interest rules, including preventing the use of multiple fiscal intermediaries (FIs) and prohibiting an FI from also serving as an MLTC or a licensed home care services agency (LHCSA).
- Personal Care Authorization Reforms: Use a centralized “conflict-free evaluation” process to standardize both fee-for-service (FFS) and managed care authorization for CDPAP and personal services, use telemedicine to facilitate the physician order process, and reduce the frequency of Uniform Assessment System (UAS) assessments from every six months to once annually.
- Wage Parity: Create a pool of wage parity funds for unrepresented home care workers who do not have health coverage through their employer or public insurance options.
- Assisted Living Program (ALP): Expand ALP capacity and increase flexibility of MLTC plans to use the ALP as an “in lieu of” alternative for members who need high hours of personal care and provide incentives to nursing homes to discharge eligible residents to ALPs.
- Promote a long-term care quality program for MLTC plans that uses established outcome metrics, promotes enrollment in integrated plans, and aligns with the State’s VBP strategy.
- Telehealth and Telemedicine: Encourage MLTC plans to use telehealth modalities to complete UAS assessments and to substitute for personal care when appropriate.
- Electronic Visit Verification (EVV): Permit consumers and providers to choose among verification models, rather than adopting a single statewide model.
- Non-Medicaid Long-Term Care Services: Encourage use of non-Medicaid long-term care services to delay Medicaid enrollment by creating a consumer website through NY State of Health to enable consumers to purchase packages of personal care hours from home care agencies and increase awareness of the State Office for the Aging’s (SOFA) Expanded In-Home Services for the Elderly Program (EISEP).
- Aging Population Advisory Group: Create an advisory group of stakeholders to analyze and address the growing aged population and the resources it will require, including the following issues: housing development to enable aging in place, long-term care capacity across service modalities, tax policy and estate planning, and private long-term care insurance reforms.
In addition to the proposals advanced by the LTCAG, the MRT 2 discussed proposals received from the public. These included, among others, proposals to impose a 60-month lookback period for community-based long-term care services and to eliminate spousal refusal for spouses living together in the community when the applicant is not an institutionalized spouse and parental refusal for parents living with their child. They also included proposals to limit the number and activities of CDPAS FIs and restrict the individuals who may serve as personal assistants. The stakeholder proposals also included recommendations to include ALP in the mainstream and MLTC benefit packages, to reduce nursing home rates for residents eligible for ALP, to eliminate partial capitation MLTC, and to authorize MLTC plans to sell products on the commercial market. Stakeholders also proposed to extend to mainstream managed care the same limits on personal care eligibility and fair hearing reforms that were recommended for MLTC.
The MRT 2 also discussed several non-emergency transportation proposals to address rising spending in taxi and livery services, which has been observed in both managed care and FFS and both in dollars per member and trips per member. These proposals included using a transportation broker to manage this benefit, excluding transportation from the MLTC benefit package, reducing taxi/livery reimbursement rates, implementing ambulance diversion programs, and maximizing federal reimbursement for these services through certified public expenditures by municipalities.
Managed Care and Care Management
The managed care proposals under review appear to focus on mainstream managed care, although their applicability to MLTC plans is unclear. They include proposals to restore quality and VBP funding, as well as proposals to eliminate them. In addition, the MRT 2 received proposals to withhold administrative payments from plans that submit incomplete encounter data, to reduce inappropriate payment denials, to require contracts with behavioral health providers that accept Medicaid FFS rates, and to implement VBP for personal care.
The MRT 2 considered a variety of care management proposals affecting health homes, patient-centered medical homes, and prevention and chronic disease management programs. In particular, the MRT 2 received proposals to eliminate health home outreach payments, focus resources on high-acuity members, and consolidate health home networks.
Program Integrity, Hospitals, Pharmacy
The program integrity proposals include maximizing the use of third-party health insurance as the primary payer; expanding the State’s ability to impose monetary penalties on managed care plans for fraud, waste, and abuse; requiring home care aides to obtain unique personal identifiers; strengthening overpayment self-disclosure requirements; and enforcing requirements to bill Medicare first for dual eligibles. This category also includes strengthening the role of county departments of social services in fraud referrals and oversight of pooled trusts, maximizing use of Veterans Affairs (VA) benefits through marketing and enrollment assistance, reimbursement eligibility verification, expanding estate recoveries, and enhancing the Asset Verification System to include local banks.
The hospital proposals focus principally on targeting voluntary hospital indigent care dollars to safety net hospitals, enabling NYC Health + Hospitals and other safety net hospitals to engage in capitated risk arrangements, replacing Indigent Care Pool Disproportionate Share Hospital (DSH) funds with Intergovernmental Transfer DSH funds, and reducing capital reimbursement rates for hospitals.
The MRT 2 also reviewed a series of pharmacy proposals aimed at reducing Medicaid spending on prescription medications.
The MRT 2 covered not only savings recommendations, but also recommendations to raise health-related taxes to support Medicaid expenses. These include a tax increase on for-profit insurers, health plan profit caps, and an individual insurance coverage mandate.
Health workforce proposals, broadly defined, to expand the supply of direct care workers and improve retention were also included in the discussion. These included working with the State Education Department (SED) to modernize scope of practice. Several proposals advanced by LeadingAge NY were discussed, including authorizing medication technicians in nursing homes, allowing hospice in ALPs, promoting training and supports for direct care workers such as home care aides, and a universal worker training program.
Health IT and Telehealth
The meeting also included a discussion of health IT and telehealth strategies to improve access and quality. Specifically, proposals call for a statewide telehealth platform to reduce interoperability barriers; expansion of telehealth models of care to include behavioral, oral, maternity, and high-need populations; an increase in telehealth reimbursement rates; and a goal to deliver broadband coverage across the state. Proposals also seek to modernize Medicaid data technology and expand access to data. This would include integration of claims and clinical data, improved data exchange, expansion of the Statewide Health Information Network for New York (SHIN-NY), improved patient data-sharing consent, and a comprehensive review of State health IT to drive efficiencies.
Social Determinants of Health (SDH)
Proposals on this topic include establishing regional SDH networks as a single point of contracting per region for SDH services provided by a network of community-based organizations (CBOs). Networks would utilize a statewide IT platform to coordinate and utilize a uniform social risk factor tool to assess Medicaid recipients and determine need. State Medicaid Director Donna Frescatore and others commented that, if implemented, this should be married with VBP and a total cost of care approach to ensure a return on investment. Other proposals include a standardized SDH screening tool, expansion of medical respite, and medically tailored meals.
The MRT 2 will now be working to solicit additional feedback, rate the proposed suggestions, and synthesize them into more formal proposals with the goal to achieve savings. At its next meeting on March 19th, the MRT 2 is expected to vote on a set of recommendations.
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