NHTD and TBI Waiver Transition Workgroup Meeting

November 16, 2016, 10:00 am – 12:00 pm

One Commerce Plaza, Room 1613
Albany, NY 12210

Welcome and Introduction, David Hoffman, Bureau Director, Bureau of Community Integration and Alzheimer´s Disease

  • Introduction of Workgroup members.
  • Review of meeting agenda:
    1. Rate Setting Methodology, Torrey Duchessi & Michael Dembrosky, NYSDOH, Division of Finance and Rate Setting;
    2. Review Frequently Asked Questions – Questions and Comments; and
    3. Next Steps.

Rate Setting Methodology, Torrey Duchessi & Michael Dembrosky, NYSDOH, Division of Finance and Rate Setting

  • "Managed Care Rate Setting Overview" presentation will be posted on the MRT website after the meeting.
  • The history of Medicaid Fee for Service will be used as a basis to ease the transition into Managed Care.
  • Fair and reasonable reimbursement will support budget predictability and stay within fiscal limits.
  • Rates should stay flexible and reflect operational and fiscal liabilities.
  • Trends such as inflation and utilization will be taken into account.
  • Managed Care plans are expected to reach a certain level of efficiency.
  • The State will pay the Managed Care Plans a monthly rate. The plan then contracts with each service provider which will be paid different amounts based on need and risk adjustment. The data from the entire TBI or NHTD population will drive what the average payment will be.
  • During the two –year continuity of care period, providers who serve five (5) or more participants are guaranteed the same rate that the State is currently paying. During that two (2) years, they will negotiate.
  • Medical Loss Ratio baseline from federal guidance is 85%. This means 85% for PMPM, leaving 15% for care management/administrative costs and profit.
  • Each plan receives a risk score. NYSDOH´s Office of Quality and Patient Safety sets these scores and monitors.
  • Workgroup comments and questions:
    1. A workgroup member asked what type of efficiencies do they see for our population? M. Dembrosky responded that the rate setting process has not begun for this population but 3M will be looking at potentially preventable hospitalizations, incidents, inpatient admissions, etc. They are looking at a statewide benchmark and outliers that a person can benefit from a Managed Care setting. This is already being tracked on the Mainstream Managed Care side.
    2. A workgroup member asked if the two (2) year rate guarantee is subject to their status? Example given: the number of hours approved for a service increases/decreases. The Department responded that the current plan does not have a guarantee on the number of service hours.
    3. A workgroup member asked about the requirements for a plan´s network of providers. The Department responded that plans need to have adequate network capacity/choice, which is at least two (2) providers per county.
    4. A workgroup member asked if regional differences and costs are evaluated when setting rates. M. Dembrosky responded yes, regional rates are considered when developing rates.
    5. A workgroup member asked if NYSDOH has done a comparative analysis of the differences between CFCO rates vs. 1915c waiver rates. The Department responded that CFCO rates have not been established yet, so this analysis remains outstanding.
    6. A workgroup member expressed concern that the 2015/2016 FLSA rate has not been included. The Department responded that once CMS approves the waiver application, their intent is to add the .34 increase retroactively. M. Dembrosky responded that draft rates will hopefully be sent to plans in October 2017.
    7. A workgroup member expressed concerns that the plan care Managers are not responsive to members´ needs. The Department responded that it is not aware of any trend that suggests this problem. Currently, when this type of problem occurs, the RRDC will intervene and help facilitate a resolution to a problem. NYSDOH needs to know about specific instances that providers or plans have identified. Many of these issues routinely are addressed through the Mainstream and MLTC complaint lines.
    8. A workgroup member expressed concerns regarding the costs associated with transportation. The Department responded that social transportation will be a CFCO service. Transportation costs are carved out of Mainstream services.
    9. A workgroup member expressed concerns regarding increased administrative costs for providers associated with the transition from a fee for service system to Managed Care and the timeliness of reimbursement.

Review Frequently Asked Questions – Questions and Comments

  • The Department advised the workgroup that DOH received 36 written comments to the draft transition plan.
    1. The most common concerns were related to Conflict –Free Case Management and the UAS.
    2. One –third of the comments were opposed to the transition.
    3. 20% of concerns were related to CFCO.
    4. 14% of concerns were related to rates.
    5. NHTD currently has 2,416 participants enrolled.
    6. TBI currently has 3,188 participants enrolled.
  • At the request of the workgroup, the Department provided an overview of MLTC.
    1. MLTC is a type of insurance plan existing for 25 –30 years.
    2. Seven or eight years ago, there were approximately 3,000 –4,000 people enrolled. Enrollment today is up to 175,000.
    3. MLTC includes MAP, FIDA., Partial Capitation and PACE plans.
    4. MLTC predates the Affordable Care Act (ACA) and Medicaid Redesign Team (MRT).
    5. CFCO was introduced as part of the ACA and was meant to open the door to those in Mainstream, FFS and MLTC in order to expand access and availability of community –based long term services and supports. New York was one out of seven states that have approved state plan amendments to offer CFCO services (California, Maryland, Montana, Oregon, Texas, Washington, and New York). The number of people eligible for CFCO services outweighs the number of people eligible for waiver services.
    6. It is unknown what will happen to the ACA/CFCO after President Elect Donald Trump takes office. However, NYSDOH remains committed to continue the plan to transition the adult 1915c waivers to Managed Care in January 2018.

Meeting Wrap Up

  • Several workgroup and audience members expressed concerns about Service Coordination and the CMS requirements that it be provided as a conflict free service.
  • A workgroup member suggested that since the Waiver Transition Plan addresses Service Coordination in a Managed Care system, the issue of conflict of interest is resolved. NYSDOH continues to be actively engaged with CMS regarding this issue.
  • The next meeting will be scheduled after the first of 2017.

Meeting was adjourned at 12:00 pm.