2013-14 Executive Budget

MEDICAID Proposals
Investments / (Savings)

($ in Millions)

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No. Initiative Effective Date Art VII 2013-2014 Impact 2014-2015 Impact Description
Yes/No Gross State Gross State
Affordable Housing
  Additional Supportive Housing April 2013 No $12.50 $12.50 $12.50 $12.50 New York seeks to dedicate $91.35 million in State Fiscal Year 2013-14 to expand access to supportive housing services. This proposal would: 1) continue $75 million in MRT dollars to fund various supportive housing initiatives; 2) allocate $12.5 million in new funds; and 3) designate $3.85 million to fund new supportive housing initiatives associated with Medicaid savings derived from the closure of hospital and nursing home beds.
  Supportive Housing (related to Nursing Home and Hospital Closures) April 2013 No $0.00 $0.00 $0.00 $0.00 Funding is generated from Medicaid savings ($3.85 million state) associated with the closure of two nursing homes and two hospitals, and the decertification of nursing home and hospital beds, effective April 1, 2012. Funding will be used for MRT supportive housing initiatives.
Totals $12.50 $12.50 $12.50 $12.50  
Basic Benefit Review
  Tobacco Cessation Counseling by Dentists July 2013 No $3.00 $1.50 $4.00 $2.00 This proposal will expand access to tobacco counseling by reimbursing dentists and will provide greater access to effective, high quality smoking cessation treatment for members. Various meta-analyses have found that smoking-interventions delivered by non-physician clinicians are effective in increasing abstinence rates among smokers. Increased abstinence rates are associated with better health and lower cost.
  Lumbar Discography October 2013 No ($0.05) ($0.03) ($0.11) ($0.06) Discography is a diagnostic procedure used to determine if the lumbar disc is the source of low back pain and results may put patients at risk for undergoing surgery. Pursuant to the recommendation of the MRT Basic Benefit Review Work Group, coverage of lumbar discography for chronic low back pain will be discontinued due to the lack of medical evidence and the potential for patient harm.
  Transcutaneous Nerve Stimulation (TENS) for the Treatment of Pain October 2013 No ($1.26) ($0.63) ($2.52) ($1.26) TENS is commonly prescribed for pain treatment. Pursuant to the recommendation of the MRT Basic Benefit Review Work Group, Medicaid will limit coverage of TENS to pain associated with knee osteoarthritis. There is a lack of evidence to support the efficacy of TENS for such use other than osteoarthritis of the knee.
  Implantable Infusion Pumps for Non-Cancer Pain October 2013 No ($0.14) ($0.07) ($0.27) ($0.14) Infusion pumps are surgically implanted to provide round-the-clock drug therapy for pain management for chronic non-cancer pain ( e.g., arthritis, low back pain, etc.). Pursuant to the recommendation of the MRT Basic Benefit Review Work Group, coverage for implantable infusion pumps, except in cases of intractable cancer pain, will be discontinued due to insufficient evidence and the potential for patient harm. Serious drug and device related adverse events, including death may occur with infusion pumps.
Totals $1.55 $0.77 $1.10 $0.54  
Managed Long Term Care
  MLTC Ombudsman April 2013 No $3.00 $1.50 $3.00 $1.50 This proposal will establish a MLTC specific ombudsman effort to provide a resource for consumers and families to help navigate plan benefits, appeal rights, and all other aspects of managed long term care.
Totals $3.00 $1.50 $3.00 $1.50  
Payment Reform & Quality Measurement
  Increase NH Quality Pool April 2013 No $10.00 $5.00 $10.00 $5.00 This proposal increases the 2013 NH Quality Pool from $50 million to $60 million. The current quality measures include MDS measures, employee flu immunization, and nursing home staffing.
  Develop Price for Specialty Nursing Homes April 2013 Yes $0.00 $0.00 $5.00 $2.50 This proposal authorizes a pricing methodology to be developed for the operating component of the rate for Specialty nursing homes (i.e., pediatric, AIDS, TBI, behavioral and ventilator nursing homes or units). The new methodology would apply to rates beginning on April 1, 2014. The $5 million allocated in FY 2015 will help smooth the transition to the new price.
  Essential Community Provider Network and Vital Access Providers April 2013 No $52.00 $26.00 $24.00 $12.00 The Essential Community Provider Network (short-term funding) and Vital Access Providers (ongoing rate enhancement or other support) ensure access to care for patients. New York State will assume an active role in ensuring certain essential community providers (hospitals, nursing homes, D&TCs or home health providers) will be eligible to receive short-term funding to achieve defined operational goals such as a facility closure, merger, integration or reconfiguration of services. This proposal will increase the total VAP/Safety Net pool to $182 million in 2013-14 and $153 million in FY 2014.
  Reallocate $30M from the NH Financially Disadvantaged Program to the VAP/Safety Net Program for Nursing Homes April 2013 Yes $0.00 $0.00 $0.00 $0.00 This proposal eliminates the statutory authorization for the $30 million Financially Disadvantaged Program for nursing homes to effectuate the reallocation of these resources to nursing home providers under the VAP/Safety Net Program.
Totals $62.00 $31.00 $39.00 $19.50  
Additional Considerations
  Indigent Care Pool Reform/Voluntary UPL Payment April 2013 Yes $25.00 $12.50 $25.00 $12.50 Bring ICP methodology into compliance with Federal DSH requirements by basing methodology on Medicaid and uninsured loses and excluding bad debt.
  Reduce APG Investment for Hospital Outpatient Payments April 2013 Yes ($25.00) ($12.50) ($25.00) ($12.50) Revise statutory language to reflect reduction to APG investment reflected in prior year appropriation language.
  Health Homes Infrastructure Development and Governance Support Grants April 2013 Yes $15.00 $15.00 $0.00 $0.00 The formula developed by the Commissioner will instruct funds to be distributed to Health Homes based upon a lack of prior access to funding from HEAL and Federal CMA Innovation Grants, as well as geographic and demographic factors.
  Health Home Plus Design targeted at AOT/State Psychiatric Center Discharges April 2013 No $10.08 $2.02 $10.08 $5.04 The Assisted Outpatient Treatment (AOT) is a program for high need/risk individuals with serious mental illness. As evidenced by recent tragic events, the capacity of the AOT program needs to be strengthened. Health Home Plus programs will be embedded in designated health homes to more effectively manage the care of people assigned to AOT. Funds will be used to support patient caseloads, tracking, and other compliance activities, as well as sharing care management records across networks.
  Integration of Behavioral and Physical Health Clinic Services April 2013 Yes $15.00 $7.50 $15.00 $7.50 This proposal includes funding for two separate initiatives that support integration of evidence based behavioral and physical health services to Medicaid patients: Service Integration Licensure Pilot Project and the Collaborative Care model. Patients receiving care at Pilot clinics will be able to obtain coordinated physical and behavioral health services whose goal is to improve overall health. The Collaborative Care model will promote, in primary care settings, the detection and treatment of common mental health conditions such as depression. Patients with a mental health condition may not adhere to treatment plans for illness such as diabetes or hypertension. Treating the mental health condition will therefore improve overall patient physical health.
  Reinvest Savings Related to the Elimination of Trend Factor for Certain Providers April 2013 Yes $0.00 $0.00 $0.00 $0.00 The savings attributable to the elimination of the trend factor for 1) foster care will be reinvested in a pay performance/quality pool and 2) pediatric nursing homes will be reinvested to smooth the transition to a new price, which will serve as benchmark rate for the transition to Managed Care.
  Minimum Supplemental Rebates October 2013 Yes ($0.90) ($0.45) ($1.78) ($0.89) Require manufacturers of brand drugs that are eligible for State public health plan reimbursement to provide a minimum level supplemental rebate to the State. If a rebate is not provided by the manufacturer, prior authorization may be required.
  Eliminate Prescriber Prevails for Atypical Antipsychotic Drug Class (MCOs) July 2013 Yes ($18.75) ($9.38) ($25.00) ($12.50) DOH is required to approve a prescriber's request for prior authorization of a prescription drug regardless of whether clinical criteria has been met. This proposal would eliminate the prescriber prevails provision and supports Federal regulations that prohibit payment for experimental, investigational or unproven medical treatment.
  Eliminate Prescriber Prevails for All Classes of Drugs (FFS) July 2013 Yes ($2.07) ($1.04) ($2.70) ($1.35) This proposal is consistent with the above proposal and eliminates the prescriber prevails provision for Medicaid FFS for all classes of drugs.
  Eliminate Prescriber Prevails for Opioids in Excess of Four Prescriptions in a 30 Day Period July 2013 Yes ($0.03) ($0.02) ($0.04) ($0.02) This proposal will allow the Department to deny prior authorization for opioid analgesic prescriptions in excess of 4 prescriptions in a 30 day period, when clinical criteria as established by FDA and manufacturer guidelines, official compendia, the Medicaid Drug Utilization Review Board (DURB) and the Pharmacy & Therapeutics Committee (P&TC) are not met.
  Reduce FFS Pharmacy Reimbursement Rate to AWP Minus 17.6% July 2013 Yes ($3.60) ($1.80) ($4.80) ($2.40) This proposal reduces FFS pharmacy brand reimbursement rate from Average Wholesale Price (AWP) minus 17% to AWP minus 17.6% which reflects the rate achieved by the managed care plans.
  Eliminate Summary Posting Requirement for P&TC Meetings April 2013 Yes ($0.36) ($0.18) ($0.28) ($0.14) This will eliminate the requirement to provide a written P&TC summary notice and allow electronic meeting recordings to serve as public notice. This will enable the Department to implement changes to the Preferred Drug List (PDL) more efficiently, and expedite the earning of supplemental rebates.
  Tighten Early Fill Edit July 2013 Yes ($0.80) ($0.40) ($1.06) ($0.53) Currently, beneficiaries are able to obtain up to an extra 90-day supply of medications over the course of 360 days. This proposal would tighten the FFS pharmacy early fill edit to ensure ample supply and reduce waste so that prescriptions can only be refilled when the amount of medication on hand is equal to or less than a 7-day supply.
  Incontinence Supply Contractor April 2013 Yes ($2.50) ($1.25) ($5.00) ($2.50) Authority to contract for management and provision of incontinence supplies using existing provider network. Savings realized from reduction in per unit cost obtained through leveraging Medicaid's bulk purchasing power, potentially combined with purchasing for State and county-run inpatient and residential facilities. Estimate is preliminary based on survey of other State Medicaid efforts and previous contract pricing for State facilities.
  Hearing Aid Administrative Streamlining October 2013 No ($0.25) ($0.13) ($0.50) ($0.25) DOH to propose regulation change to facilitate transition from paper to electronic billing to reduce administrative burden on providers and the State. For the 24 types of hearing aids currently covered, DOH will seek industry and stakeholder input on development of maximum fees based on an average cost of products representative of each type of hearing aid. This will allow automated processing of claims and is consistent with current regulations and procedures for complex wheelchairs and other equipment as well as other payors nationwide.
  CSWs to Bill Medicaid April 2013 Yes $2.50 $1.25 $2.50 $1.25 This proposal authorizes Certified Social Workers to bill Medicaid for mental health services to children under 21 and for those requiring such services due to pregnancy or child birth.
  Medicaid Early Intervention Restructuring April 2013 Yes ($1.43) ($0.48) ($5.70) ($1.90) Integrating covered EI services into the Managed Care program; using supplemental evaluations to established re-referred EI children; require screening of children referred to EI with a diagnosis; using medical and other records to establish eligibility for EI.
  Increased MLTC Rate for Members Relocating from Adult Homes July 2013 No $0.20 $0.10 $0.20 $0.10 Increase the MLTC rate for current residents of adult homes who relocate to more independent living residences.
  Gold STAMP Program to Reduce Pressure Ulcers April 2013 No $0.50 $0.50 $0.00 $0.00 These funds will be used to extend the Gold STAMP efforts through 2013 by establishing 4 additional collaboratives in those areas of the State that have not yet been targeted or are underserved. Funds will also be used to enhance marketing of the initiatives Statewide and to perform an evaluation to determine the effectiveness of the Gold STAMP model on poor performing providers.
  Managed Long Term Care Quality Incentive April 2013 No $20.00 $10.00 $20.00 $10.00 Similarly, we are proposing to initiate the Managed Long Term Care Quality Incentive (MLTC QI) in FY 2014. The MLTC QI will use established measures of quality, satisfaction and plan performance to rank plans. A dividend would be paid to plans that have high levels of performance in these areas, with the intention of establishing the MLTC QI as part of the annual rate setting process for MLTC plans.
  ALP Targeted Expansion and Debt Service April 2013 Yes $0.00 $0.00 $0.00 $0.00 Provides for up to 4,350 additional ALP beds for "transitional " adult homes through an RFP process. Allows for limited capital reimbursement for these new beds pursuant to Commissioner regulations.
  Balance Incentive Program Implementation April 2013 No $20.00 $10.00 $0.00 $0.00 BIP is a provision of the Affordable Care Act to provide enhanced long term services which will allow NYS an opportunity to receive significant enhanced FMAP over the duration of the grant.
  Spousal Support April 2013 Yes ($68.60) ($34.30) ($137.00) ($68.50) State Social Services law is amended to conform with Federal law with regard to spousal contributions and responsibilities for spouses residing together in the community. This amendment, which has been proposed in the past, will eliminate the ability of non applying spouses to refuse to contribute toward the cost of care for the applicant spouse.
Totals ($16.01) ($3.05) ($136.08) ($67.09)  
Federal Health Care Reform
  Federal Health Care Reform January 2014   $0.00 ($43.00) $0.00 ($43.00) Additional Federal Financial Participation becomes available for childless adults in January 2014.
  Repeal Family Health Plus January 2014 Yes $0.00 $0.00 ($106.00) ($38.50) The ACA establishes a new mandatory coverage group for adults to 138% of FPL. As such, all FHP enrollees will be subsumed into the new Medicaid eligibility category. The adults with incomes between 138% of FPL and 150% will be able to enroll in a QHP with a tax credit. The State will wrap the QHP co-premium and cost-sharing for those who were previously enrolled in FHP. There is no longer a need for the current FHP program.
  Define the Medicaid Benchmark Plan as the Current Medicaid Benefit (without Nursing Home Care) January 2014 No $0.00 $0.00 $307.00 $115.13 The ACA requires states to enroll the new adult eligibility group into a benchmark plan. The benchmark plan can be the state's Medicaid benefit or it can be one of four other benchmark options. 1.1 million adults subject to the benchmark benefit are already enrolled in Medicaid or FHP and of those 60% are enrolled in Medicaid. Choosing the Medicaid benefit would be the least disruptive to current enrollees, easier to administer, preserves continuity of coverage as income fluctuates, and eliminates the need to separately identify persons with disabilities or other special health needs who cannot be mandated into a lesser benefit than the full Medicaid benefit and move them into another eligibility category.
Totals $0.00 ($43.00) $201.00 $33.63  
Grand Totals $63.05 ($0.28) $120.52 $0.58