9/10/2013. The Session s Focus. Status of the NYS FIDA Initiative

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1 Leading Age NY Financial Manager s Conference, September 10-12, 2013 The Otesaga Resort Hotel, Cooperstown NY Paul Tenan VCC, Inc. FIDA: An Overview and Update The Session s Focus Overview of CMS national FIDA Initiative, including Current Status. Summary of the NYS-CMS Memorandum of Understanding, completed August 26, NY FIDA demonstration s timetable. Implications of demonstration within its service area. Implications that the FIDA demonstration can have upon important aspects Medicaid Redesign initiatives through Status of the NYS FIDA Initiative The Memorandum of Understanding between CMS and NYS was signed on August 26, Culmination of a nearly two year effort, and one of the most significant objectives from the Medicaid Redesign Initiative. Key dates related to Enrollment: Individuals receiving Community based LTSS Voluntary enrollment Effective, July 2014 Passive enrollment Effective September, 2014 Individuals receiving Facility based LTSS Voluntary enrollment Effective, October, 2014 Passive enrollment Effective January, 2015 Demonstration ends December 31,2017, unless extended. 3 The CMS Financial Alignment Initiative National Perspective 4 The CMS objective is to test two models to better align Medicare and Medicaid financing and reduce or eliminate a longstanding barrier to coordinating care across the two programs benefits. The initiative was introduced in July, Twenty six states submitted proposals based upon either a managed fee for service or a capitated model. NYS became the seventh state to complete a MOU to implement the demonstration. 1

2 Similarities Across the Financial Alignment States 5 The 26 state applicants have % of their Medicaid-Medicare covered persons as Full Benefit enrollees (2007). Full benefit enrollees demonstrate greater utilization of skilled nursing, home health, prescription drugs, physician services, acute care and emergency room services (2007). Nationally, the full benefit enrollees are more than four times as expensive as the Medicare only enrollees (2007). Among the 26 demonstration states, Medicare expenditures account for % of total expenditures for full benefit Medicaid Medicare enrollees (2007). In 2011 and before onset of CMS Initiative, there were nine states with some form of integrated care for Medicaid Medicare enrollees other than PACE. NYS FIDA Demonstration Characteristics An estimated 170,000 Medicare-Medicaid eligible to join a Fully Integrated Duals Advantage ( FIDA ) plan. The majority are currently enrolled with MLTC plans. The demonstration s service area is NYC, and Nassau, Suffolk, and Westchester Counties. This is a capitated risk model undertaken by MLTC plans, or Medicaid Advantage plans. Twenty-five plans are currently under review to become FIDA plans. 6 The FIDA Regional Demonstration. Participant Eligibility Age 21 or older Entitled to Medicare Part A benefits and enrolled with Parts B and D, and receiving full Medicaid benefits Reside in a service area county. Clinical eligibility: 7 Nursing facility clinically eligible and receiving facility based Long Term Care Support Services (LTSS) Eligible for Nursing Home Transition and Diversion (NHTD) waiver, or Require community based LTSS for more than 120 days. The FIDA Regional Demonstration. 8 Participant Eligibility, cont d: Individuals that are eligible for FIDA enrollment but will not be passively enrolled include: PACE enrollees Medicare enrollees in Special Needs Plans for institutionalized individuals Enrollees in Health Homes Those assigned to a Medicare ACO Those participating in the CMS Independence at Home demonstration Those enrolled in Employer or Union sponsored coverage for employees or retirees 2

3 Enrollment Individuals receiving Community based LTSS Voluntary enrollment Effective, July 2014 Passive enrollment Effective September, 2014 Individuals receiving Facility based LTSS Voluntary enrollment Effective, October, 2014 Passive enrollment Effective January, 2015 An independent third party will act as the enrollment broker and facilitate enrollment. FIDA plans are prohibited from marketing directly to participants; they may respond to participant requests, participate in group marketing events, and provide general audience materials. Details and guidance is still to be developed. Some mandatory and notice marketing materials will require advanced approval by CMS and NYS. 9 Passive Enrollment The algorithm to be employed by the Enrollment Broker will favor continuity of providers / services, including enrollee s existing relationship with MLTCPs. Implementation details and processes to be developed. 10 Participant Choice FIDA eligible Medicare Medicaid covered persons have the right to choose: Participation in demonstration Plans Providers Their care manager and members of their interdisciplinary care team and, Self directed care as a covered option. Participants can opt out of the FIDA demonstration, or transfer between FIDA plans at any time during year. All changes are effective on the first day of the following month. 11 Care Plan Development and Management Comprehensive Assessment must be conducted within 30 days of enrollment. Conducted in the home by an RN using state approved assessment instrument. Assessment is basis for the Person Centered Services Plan (PCSP). Reassessments and PCSP update must be completed at least every six months after initial assessment completion date; and When there is a change in patient s status, or When there is a significant health care event such as hospital admission, change in care setting, change in functional status, loss of caregiver, or change in diagnosis. 12 3

4 Care Plan Development and Care Management Responsibility of Interdisciplinary Team (IDT) IDT makes coverage determinations that may not be modified by the FIDA plan outside of the IDT s actions. The Care Plan developed by IDT and accepted by enrollee is basis for service authorization to network providers. Assistance to receive service is responsibility of IDT. Coverage decisions are an eligible appeal subject for a participant. IDT membership consists of the assigned care manager, the participant or designee, primary care physician, behavioral health professional, participant s home care aide, and other providers requested by the participant or recommended by the care manager. 13 Continuity of Care At time initial enrollment, Participants have access to all providers and authorized services according to preexisting service plans for up to 90 days, or until a comprehensive assessment is agreed upon, except for participants residing in nursing homes at time of passive enrollment. FIDA plans must have contracts or payment arrangements with all nursing homes such that nursing home residents that are passively enrolled are afforded access to that nursing home for duration of the demonstration. 14 Network Adequacy FIDA plan networks must meet existing applicable Medicare and Medicaid provider network requirements. The requirements are detailed in the MOU and other documents, and they include: At least two choices for each covered benefit Ratio and travel criteria for physicians and other medical services Choice of at least two providers within a 15 mile radius or 30 minutes of zip code of residence. A plan s network must meet minimum appointment availability, and access standards for community and facilitybased LTSS. 15 Participant Participation and Safeguards Participant Ombudsman an independent, conflict free entity that will provide free assistance to participants with accessing care, understanding and accessing rights and responsibilities, and appealing adverse decisions. Also will provide advice, information, referral and representation with FIDA plans, providers, or NYSDOH. Plans are to establish a Participant Advisory Committee that meets quarterly, and Plans are encouraged to include participant representation on board of directors. 16 4

5 Grievance and Appeals CMS and NYS are developing an integrated grievance and appeal system to simplify for participant and plan. There also is to be four levels of integrated appeals: Plan level appeal. (Benefits subject to change and the appeal must be continued pending outcome.) An adverse determination at Plan level leads to: Integrated administrative hearing conducted by Office of Temporary and Disability Assistance Medicare Appeals Council, and Federal District Court. 17 Quality 18 A Quality Assurance Performance Improvement (QAPI) process is required of FIDA plans. Plan reporting requirements include HEDIS, Health Outcomes Survey and CAHPS data to CMS and NYS. External quality reviews of FIDA plans to be conducted by a Quality Improvement Organization (QIO) and an External Quality Review Organization(EQRO). Financing and Payment 19 General Rate Provisions based on Medicare spending, based on a blend of projected MA rates, Medicare FFS projections, adjusted for FIDA pop. and risk adjustments. Part D follows regular Part D payment method. For Medicaid, largest part will be MLTC payments if made in absence of FIDA demonstration, adjusted by an estimate for cost of services paid FFS outside of MLTC rate. Risk adjustment methods apply. Medicaid will have two rate cells: a community non- NF certifiable rate cell, and nursing home certifiable rate cell. Solvency standards for FIDA to be released soon. Plan Payment to Providers 20 By , Plans must develop their proposed method(s) for a fully integrated payment system through which providers are not paid FFS, but by an alternate basis to be determined (pay for performance, bundled payment, other). After State approval and no earlier than January 2015, FIDA Plans will be required to implement the approved plans, which will remain in effect throughout duration of Demonstration. 5

6 Savings Targets 21 Quality Withholds 22 Year 1 July 1, 2014-Dec Medicare Part A & B Medicare Part D Medicaid 1% 0% 1% Year 2 CY % 0% 1.5% Year 3 CY 3% 0% 3% Note: Savings percentage applied to baseline spending projections. Medicare A&B Medicaid Year 1 1 % 1 % July 2014-Dec Year 2 - CY % 2 % Year 3 CY % 3 % Quality withhold applied to baseline spending projection, by plan. Withhold measurement elements spelled out in MOU and are expanded in Years 2 & 3. Not applicable to Part D. OPWDD Population Considerations. Generally speaking, individuals who receive OPWDD auspice services are not eligible for enrollment. NYS - CMS negotiation on People First waiver development is underway. The model includes capitated, comprehensive models known as Developmental Disabilities Individual Support and Care Coordination Organization (DISCO). The FIDA MOU s treatment of important components may well be a contributing source to important parts of a finished the People First waiver. 23 OPWDD People First Waiver Phases * OPWDD Phase 1 (voluntary enrollment) 4/1/2014 OPWDD Phase 2 (mandatory) 4/1/2015 OPWDD Phase 3 (mandatory) 4/1/2016 OPWDD Phase 4 (mandatory) 4/1/2017 OPWDD Phase 5 (mandatory) 4/1/2018 *As reported in Managed Care Transition Date, NYSDOH, draft

7 MRT Goals and Care Management for All Timetable: Relationship to FIDA Demonstration Statewide Enrollment Profile and Spending Forecast: Reported enrollment in Mainstream, FHP and HIV SNP as of is nearly 4 million. To be added by April 2018, are the remaining bulk of Medicaid benefits and covered populations. By April 2018, 95 percent of Medicaid population enrolled in care management models. Medicaid spending flowing through care management will exceed $ 45 billion, with a projected 4 percent of Medicaid spending remaining in fee for service. 25 MRT Goals and Care Management for All Timetable: Relationship to FIDA Demonstration, Cont d. 26 Populations to be added during (completed in bold): Homeless (non-duals) NYC Community Based LTC (Full Duals) Consumer Directed Personal Assistance Program(CDPAP) LTHHCP (Duals and Non-Duals) Community based LTC: Full Duals (Orange & Rockland) Full Duals (Upstate Urban) Nursing facility ( New Duals & Non-Duals, rest of State) Assisted Living Program residents HCBS waiver pops. TBI and NH Transition/Diversion Well duals Environmental Considerations as of Today: Statewide Enrollment Rate of Growth in MLTC / PACE Reported Month / Year Net Change Rate of Change from Prior Period August, , % February, ,419 Note: CMS Demonstration counties account for 97 % of enrollment, and virtually all month to month growth. 27 Plan Profile Outside of Eight County FIDA Region MLTC plans operate outside of the FIDA demonstration boundaries across 32 counties. Ten counties have at least 2 MLTC options; 5 counties have at least 3. They are Erie, Monroe, Onondaga, Albany and Rockland counties. Pending before NYSDOH as MLTC expansion are: 3 expansions proposed by downstate plans 3 Article 44 plans seeking to add MLTC as a new business line 4 MLTCs seeking additional Upstate service expansion 4 NYC based MLTCs seeking to expand Upstate 7

8 Plan Challenges with Participation in FIDA. Introducing a new plan option while offering their consumers a combination among MLTC, PACE, SNP, Medicare Advantage. Meeting solvency requirements with revenues from prior years and earned from existing plan options. Some of these plan options will see enrollment shift to FIDA plan option. How much net enrollment growth and net premium revenue will occur with FIDA? What are the costs to retain FIDA plan enrollees upon end of demonstration? 29 Plan Challenges with Participation in FIDA, Cont d. Product line Management gets more complicated: Varying enrollment processes across plan options; Different requirements in key areas participant choice, grievance and appeals, care management methods; Impact on financial management claim processing must accurately match enrollee to claims to accurate payment rate; Accurate reporting Internal and External (Encounter and other data); Added attention to member and provider communication (Plan accountability implications); Demonstrate earning back of Quality withholds; and Introduce new payment models to providers. All while living within a capped administrative Medicaid PMPM. 30 Challenges for Providers During FIDA Demonstration (and MRT Implementation Elsewhere) Be organized to manage your patient census from different plans and plan options. Be sure that important variations across plan options are spelled out in provider agreements. Be aware of service authorization procedures and care management variations across plan options (staff training is critical). Be aware of how to retain the patient when plan coverage switches. Be aware of grievance & appeal and reporting requirements that may vary across plan options. For FIDA, be versed in the Plan s Model of Care. 31 Alternatives with Provider Arrangements If not Fee for Service Same alternate basis for rehabilitation, new LTC placement, existing LTC placement? What are the mutual best practice opportunities to be supported by the alternate payment method? What operational performance objectives can the provider improve with the alternate payment method? If it works, how can you retain it upon the Demonstration ending? If the alternate payment method is in effect for less that 3 years, how will provider and plan assess its results? 32 8

9 Alternatives with Provider Arrangements, Cont d. 33 Thank You. 34 Is there a basis for strategic relationships? Are there delegated duties that may be of interest? Capacity development to meet plan enrollee needs? Care management functions? Care interventions to manage utilization of ERs and hospitalization? Cooperative strategies to manage discharge to a home living setting? Connection with a geriatric medical service? Discussion Questions Next Steps 9