LANDSCAPE UPDATE FROM DOH

  • Document is also available in Portable Document (PDF)

New York State Health Facilities Association
New York State Center for Assisted Living
62nd Annual Conference

Mark Kissinger, Deputy Commissioner Office of Long Term Care
June 29, 2011

  • New Administration
  • Medicaid Redesign Team (MRT)
  • Budget Issues - Short and Long Term
  • Federal Health Reform
  • Aggressive Timelines
  • State Budget - Next Steps
  • Global Cap
  • DOH implementation efforts are starting:
    • enrollment process changes
    • application revisions underway
    • CMS approval still needed
  • Building off 1997 law
  • Guidelines on Care Coordination
  • Palliative care recognizes the need for pain management and supports for people with serious illness or injury - not just people in the last stages of life
  • New law includes assisted living, home care, nursing homes, and hospitals
  • Adds a new option for the Partnership for Long Term Care
  • Staff are also investigating additional incentives for purchase of private LTC insurance
  • UAS
  • Bed Hold
  • Regulatory Reform

Three MLTC models in operation:

  1. Partially Capitated Managed LTC
  2. Program of All-Inclusive Care for the Elderly (PACE)
  3. Medicaid Advantage Plus (MAP)
  • Capitated for some Medicaid services only
  • Benefit package is long term care and ancillary services including home care, unlimited nursing home care
  • Primary and acute care covered by FFS Medicare or Medicaid
  • 13 plans offer this product
  • May, 2011 enrollment = 30,510
  • Census ranges from 161 to 8,991
  • DOH has had a mortatorium on the development or expansion of new partially capitated plans since 2006
  • Federal program type for Medicare and Medicaid at State option
  • Capitated for all Medicare and Medicaid services
  • Most integrated of the MLTC models
  • Day center / clinic based
  • Provider network usually small
  • Benefit package includes all medically necessary services - primary, acute and long term care
  • 7 plans now offer this product
  • May, 2011 enrollment = 3,645 Range = 47-2,610
  • 2 new PACEs are being planned or under development
  • Capitated for Medicare and Medicaid under two separate contracts (Federal and State)
  • Many plans use a Medicare Dual Eligible SNP (DE-SNP) subsetted to match MAP eligibility although this model not required
  • All plans must cover the State-defined Combined Medicare and Medicaid Benefit Package
  • Between Medicare and Medicaid - benefit package includes all medically necessary services (primary, acute and long term care)
  • Plans must meet both Medicare and Medicaid requirements
    • Challenge is to have this appear seamless to the member
  • 8 plans now offer this product
  • May, 2011 census = 1,374
  • Range = 12-471
  • 1115 Waiver approval needed from CMS before we can start
  • Require all dual eligibles who need community-based long term care services for more than 120 days to enroll in Managed Long Term Care or other approved care coordination models.
  • Eliminates the need to score as Nursing Home eligible upon enrollment
  • Definition of community-based long term care services is under development but likely candidates are:
    • Personal care services
    • Home health services
    • Adult day health care
  • Semi-Annual Assessment of Members (SAAM) will still be completed by the plans and submitted to DOH every 6 months for:
    • Risk adjustment of plan rates
    • Various data analyses
  • MLTC Plans will change to Uniform Assessment Tool when implemented
  • Other models that meet "guidelines specified by the Commissioner that support coordination and integration of services".
  • Guidelines must address:
    • Requirements in 4403-f (3)(a-i)
    • Payment methods the ensure provider accountability for cost effective quality outcomes
  • Includes Long Term Home Health Care Programs that meet the guidelines
  • Medicaid Redesign Team Workgroup has been appointed to assist in development (and other roles)
  • Guidelines to be posted on DOH website by November 15, 2011
  • Working with HRA to determine most effective, efficient way to transition people.
    • Will not take place all at once
      • Perhaps based on reassessment
      • Perhaps by borough
      • Perhaps by Medicaid number
  • Consumer Choice preferred but Auto Assignment for those who do not
  • Must ensure continuity of care plan and service provider
  • Educational component for people new to system and transitioning
  • Several groups are not eligible to enroll in MLTC or care coordination models until program features and reimbursement rates are developed.
  • These include people in:
    • Traumatic Brain Injury (TBI) Waiver
    • Nursing Home Transition and Diversion (NHTD) Waiver
    • Assisted Living Program (ALP)
    • Office of People with Developmental Disabilities (OPWDD) Wavier
  • There must be a choice of two plans, one in rural counties
  • Upstate expansion will be county by county, as sufficient MLTC plan and care coordination model capacity is developed
  • New law eliminates previous requirement for designation by Senate, Assembly or Commissioner or Health before applying
  • Applications for new entities or new lines of business and expansions have been posted on DOH website.
  • Require legal structure, contracted network, descriptions of care management model, grievance system, other programmatic areas and financial capability and capitalization
  • Statute allows up to 75 MLTC Certificates of Authority
    Current Status
    • 23 Operational
    • 2 in Application Status
    • 50 new plans could be established
      • 8 slots must be reserved for the Senate Majority Leader and Speaker of the Assembly to recommend to apply between April 1, 2012 and March 31, 2015.
  • Encourage MLTC Partial Cap Plan Expansion
  • Questions about the applications should be submitted to:
  • 2006-2011 very turbulent times
    • Rebasing,
    • Medicaid only,
    • Scale back,
    • Trend cuts,
    • Mitigation, etc.
  • State law mandates a pricing system with transition and quality adjustments
  • 2011-12 Budget Authorizes Pricing Methodology
  • Statewide Price with a Wage and Medicaid Only Case Mix adjustment
    • Effective 10/1/11 or no later than 1/1/12
  • Collaborate with the Nursing Home Industry to Refine Methodology
    • Transition Pool (Minimum of 4 years)
    • Establish a Quality Pool

Medicaid rates should:

  • Be transparent and administratively efficient; be predictable and facilitate timely payments
  • Pay reasonably and adequately for quality care for Medicaid patients
  • Encourage cost-effective care and promote efficiencies
  • Include appropriate payment adjustments to reflect cost- influencing factors
  • Encourage and reward quality care and promote care innovations
  • Encourage care in the appropriate setting; assure adequacy of alternate settings
  • Be updated periodically
  • Comply with Federal Medicaid rules
  • Reinforce health systems planning and advance state health care programs
  • Be consistent with available resources
  • rom what rate?
  • How long?
  • Size of transition adjustments
  • Phased approach
  • Measures
  • Staffing
  • Survey findings
  • Other elements
  • Duals and Non-Duals
  • Related to MRT 67
  • Exact approach still under discussion
  • Safety net facilities will be first focus
  • Participate
  • Communicate
  • Embrace Change

Any other questions? mlk15@health.state.ny.us