Changes to Medicaid Long Term Care. FIDA and mandatory MLTC for nursing home residents

Transcription

1 1/22/15 Changes to Medicaid Long Term Care FIDA and mandatory MLTC for nursing home residents Prepared for the NYSBA Annual Meeting, January 27, 2015 David Silva, Program Director of ICAN (Independent Consumer Advocacy Network) New York s Ombudsman Program for Managed Long Term Care (844) ican@cssny.org INTRODUCING ICAN 2015 CSSNY 1

2 Impact of Health Reform on Dual Eligibles and LTC Most media coverage of the Affordable Care Act has focused on programs to help the uninsured CSSNY s other health initiatives, Community Health Advocates and Community Navigator Network, also focus on these areas Medicaid expansion (MAGI) Exchange (NY State of Health, Qualified Health Plans, Premium and Cost-sharing Subsidies) But the ACA also attempts to address the high cost and low quality of care for dual eligibles and people needing Medicaid long-term care services Dual Eligibles Dual Eligible someone eligible for both Medicare and Medicaid Duals represent only 18% of Medicaid recipients, but 46% of Medicaid spending. They also experience poorly coordinated care and provider cost-shifting because they straddle multiple programs: Medicare / Medicare Advantage Partial-Cap MLTC Fee-For-Service Medicaid Part D Medigap Retiree 2015 CSSNY 2

3 Duals Demonstration One lesser known initiative under the ACA is the Duals Demonstration, a way for States and CMS to test the concept of combining Medicare and Medicaid into a single benefit, provided through a private managed care plan In NY, the duals demo is called FIDA: Fully Integrated Dual Advantage Starting 2015, all dual eligibles needing long-term care will be encouraged to enroll in FIDA plans, which will be a major change in how they obtain their medical care Medicare Medicaid Health Reform and LTC To bring down the cost and improve the quality of Medicaid LTC, New York implemented several initiatives to require people to get LTC through private managed care plans: Managed Long-Term Care (MLTC) all dual eligibles needing LTC must enroll in MLTC plans Mainstream Managed Care (MMC) all people with Medicaid-only needing LTC must get those services through their MMC plan Mandatory Managed Care for Nursing Home Residents all Medicaid recipients will be required to stay enrolled in their MLTC/MMC plans upon permanent placement in nursing homes 2015 CSSNY 3

4 Need for an Ombudsman In order to implement these initiatives, the Federal government required the State to create an independent Ombudsprogram Educate Advocate Appeal Through its subcontractors, CSSNY harnesses the existing network of organizations who have been serving this population for years Network Legal Aid Society Westchester Disabled On the Move NY Legal Assistance Group Legal Assistance of Western New York Center for Independence of the Disabled NY CSSNY CBOs ACR Health Medicare Rights Center Empire Justice Center Neighborhood Legal Services 2015 CSSNY 4

5 ICAN Network December 1, 2014 CSSNY, CIDNY, LAS, MRC, NYLAG NYC NYLAG (interim); RFP pending Nassau & Suffolk 7 January 1, 2015 WDOM Putnam & Westchester February 1, 2015 LAWNY Allegany, Cattaraugus, Chautauqua, Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca, Steuben, Tioga, Tompkins, Wayne & Yates NLS Erie, Niagara, Orleans, Genesee & Wyoming 1 2 Map of New York with Counties - Single Color by FreeVectorMaps.com 3 March 1, 2015 April 1, 2015 EJC Albany, Rensselaer, Schenectady, Columbia, Greene, Fulton, Montgomery, Schoharie, Otsego & Delaware ACR Health Onondaga, Cayuga, Herkimer, Jefferson, Lewis, Madison, Oneida, Oswego & St. Lawrence All other counties Subject to competitive procurement process The Helpline and ICAN@cssny.org Housed at Community Service Society, but calls also answered by CIDNY, EJC, LAS, MRC and NYLAG Staffed by volunteers, interns, helpline specialists and attorneys Specialists will also handle complex cases referred by helpline specialists CBOs provide in-person assistance and local community education outside of NYC Answered live from 8 a.m. 8 p.m. Mon-Fri CSSNY 5

6 Whom and With What Can ICAN Help? Whom? Current member of MLTC plan Current member of MMC plan receiving or needing LTC Current member of FIDA plan Prospective member of one of the above plans Family, friend, provider, advocate, or other representative of any of the above What? Any problem or question relating to their enrollment in MMC, MLTC or FIDA FULLY INTEGRATED DUALS ADVANTAGE (FIDA) 2015 CSSNY 6

7 What is FIDA? FIDA means Fully Integrated Duals Advantage FIDA is a type of health insurance where a private managed care company is paid by the government to provide both Medicare and Medicaid coverage to dual eligibles Think Medicare Advantage + MLTC FIDA replaces all of the different types of insurance a dual eligible might have with one single plan that covers everything FIDA Means One Card SeniorHealthChoiceWell- PlusCare MLTC Plan John Doe Member ID: ABC SeniorHealthChoiceWell- PlusCare FIDA FIDA Plan John Doe Member ID: ABC Medigap Plan F John Doe Member ID: ABC 2015 CSSNY 7

8 What does FIDA cover? Short Answer: EVERYTHING Long Answer: Doctors Hospitals Tests Preventive care Prescription drugs Over-the-Counter drugs Behavioral Health FIDA 3-Way Contract, Appendix A-1 [p. 253] Rehabilitation Therapy (PT, OT, ST) Home Care (PCA, HHA, CDPAP) Nursing Home (shortterm and long-term) HCBS Waiver Services (such as NHTD and TBI Waivers) What doesn t it cover? There are only four Medicare- or Medicaid-covered services not available through FIDA, but they can be accessed out-of-network through fee-for-service Medicare/Medicaid: Hospice Out-of-network family planning services Methadone Maintenance Treatment Program Directly Observed Therapy for Tuberculosis Disease FIDA 3-Way Contract, Appendix A.3 [p. 288] 2015 CSSNY 8

9 Who is eligible for FIDA? To enroll in FIDA, either voluntarily or passively, you must be: Age 21 or older; and Entitled to Medicare Part A and enrolled in Parts B and D; and Receiving full Medicaid benefits; and Reside in: NYC, Nassau, Suffolk or Westchester; and Newly permanently residing in a nursing home; or Are eligible for the Nursing Home Transition and Diversion Waiver (NHTD); or Require community-based Long Term Supports and Services (LTSS) for more than 120 days (this includes anyone currently enrolled in an MLTC or MAP plan). FIDA 3-Way Contract [p. 186], MOU C.1. Passive Enrollment FIDA is not mandatory However, most FIDA-eligible individuals will automatically be enrolled in a FIDA plan sometime in 2015 unless they opt out The majority of people subject to passive enrollment will be passively enrolled in a FIDA plan offered by the same company that operates their current MLTC plan Members of the following MLTC plans will be intelligently assigned to a FIDA plan from a different company to maximize the number of their MLTC providers who remain in-network: Extended MLTC HHH Choices Montefiore MLTC UnitedHealthcare 2015 CSSNY 9

10 Opt-Out At any time prior to an individual's passive enrollment date, he/she may choose to opt-out of FIDA Opting out ensures that neither CMS nor the State will passively enroll the individual into a FIDA plan for the life of the demonstration Individuals may opt out by calling either MEDICARE or N.Y. Medicaid Choice ( ). Within 1-2 weeks of completing the opt-out request, the individual should receive written confirmation by mail MMP Enrollment Guidance (E) [pp ]. Voluntary Enrollment FIDA-eligible individuals may voluntarily enroll in FIDA at any time (once enrollment begins in their region) There is no lock-in or open enrollment period; individuals can disenroll or switch FIDA plans at any time, effective the first of the next month Individuals can voluntarily enroll in FIDA even after opting out of passive enrollment MMP Enrollment Guidance 40.2, 40.3 [pp. 41, 49]; Appendix 5: State-Specific FIDA Enrollment Guidance for NY [pp. 9-12] CSSNY 10

11 Disenrollment FIDA participants can disenroll for any reason FIDA participants can only be involuntarily disenrolled for specific reasons: Loss of eligibility for FIDA Absence from plan service area for more than 6 months Material Misrepresentation Regarding Third-Party Reimbursement Disruptive behavior (but only after serious effort to resolve, multiple notices to member, and approval by CMS) Fraudulent enrollment application or abuse of FIDA card Participant knowingly fails to complete any necessary release form MMP Enrollment Guidance 40.2, 40.3 [pp. 41, 49]; Appendix 5: State-Specific FIDA Enrollment Guidance for NY [pp. 9-12]. Who will not be passively enrolled? New York will not passively enroll individuals who: Are enrolled in a PACE; Have employer or union sponsored health or drug coverage; Are confined in a correctional facility; Have opted out of passive enrollment into FIDA; Are Native Americans exempt from joining an MLTC plan; Are eligible for the MBI-WPD and are nursing home certifiable; Are Aliessa Court-Ordered Individuals (i.e., PRUCOL); Are in a Medicare Advantage Institutional Special Needs Plan (I-SNP); Are enrolled in Health Homes; Are assigned to a CMS Accountable Care Organization (ACO); Are participating in the CMS Independence at Home demonstration; Have End-Stage Renal Disease (ESRD); or Are eligible for the Nursing Home Transition & Diversion (NHTD) waiver. MMP Enrollment Guidance (E) [pp ], Appendix 5: State-Specific FIDA Enrollment Guidance for NY 10(A) [pp. 6-7] CSSNY 11

12 FIDA Regions Region 1 NYC and Nassau Voluntary: Dec Passive: April Aug 2015 Region 2 Suffolk & Westchester Voluntary: April 2015 Passive: July 2015 Map of New York with Counties - Single Color by FreeVectorMaps.com FIDA Enrollment Notices Name of Notice Sender Recipients Comments FIDA Announcement Letter DOH All FIDA-eligible individuals in demo region (this includes some people exempt from passive enrollment) 90-Day Letter DOH All individuals subject to passive enrollment in each region. 60-Day Passive Enrollment Notice 30-Day Passive Enrollment Notice NY Medicaid Choice NY Medicaid Choice All individuals subject to passive enrollment in each region. All individuals subject to passive enrollment in each region. Overview of FIDA, plan list, contact info for NY Medicaid Choice and ICAN, but no info on passive enrollment or opt-out Same as Announcement Letter Specifies which plan individual will be passively enrolled into and on what date Same as 60-day notice 2015 CSSNY 12

13 Timing of Notices and Passive Enrollment: Region 1 (non-ssi)* Medicaid renewal expires in Jun-Aug 2015 Sep-Nov 2015 Dec Jan 2016 Feb-Mar 2016 Apr-May 2016* 90-Day Notice * See note on next slide. 60-Day Notice 30-Day Notice Effective Date of Passive Enrollment January February March April 1, 2015 February March April May 1, 2015 March April May June 1, 2015 April May June July 1, 2015 May June July August 1, 2015 Timing of Notices and Passive Enrollment: Region 1 (SSI) Birthday in 90-Day Notice 60-Day Notice 30-Day Notice Effective Date of Passive Enrollment Jan-Mar January February March April 1, 2015 Apr-Jun February March April May 1, 2015 Jul-Sep March April May June 1, 2015 Oct-Dec April May June July 1, 2015 All others* May June July August 1, 2015 * Any other eligible individual that would have qualified for passive enrollment between April 1, 2015 and August 1, 2015 but was not passively enrolled, and eligible individuals who are eligible for Passive Enrollment but are not due for Medicaid renewal between June 1, 2015 and May 1, Also includes eligible individuals who are new to nursing homes as of January 1, CSSNY 13

14 Timing of Notices and Passive Enrollment: Region 2 All individuals in Region 2 90-Day Notice 60-Day Notice 30-Day Notice Effective Date of Passive Enrollment April May June July 1, 2015 Source for all timetables is DOH PowerPoint presentation, FIDA and MLTC Update (presented at Managed Care Policy and Planning Meeting, October 16, 2014) Advantages of FIDA FIDA was carefully designed to be a significant improvement over how duals currently receive their healthcare. Convenience of one plan for all covered services No more cost-shifting between Medicare and Medicaid by providers No more navigating multiple provider networks (e.g., doctors who take Medicare but not Medicaid) IDT team-based, person-centered care planning No out-of-pocket costs (except spend-down) Access to Medicaid waiver services 2015 CSSNY 14

15 Disadvantages of FIDA It s a personal decision whether FIDA is a good idea for a particular individual. Unlike Original Medicare, with FIDA you can generally only see doctors and other medical providers who participate in the plan s network Exception: Guildnet FIDA has a POS network, so they will cover any provider who takes Original Medicare (and will pay the Medicare rate) Unlike Original Medicare, prior approval may be required for certain procedures and services These issues do not represent disadvantages for the 35% of duals in Medicare Advantage plans, who have already become accustomed to a managed care system IDT A central feature of FIDA is the Interdisciplinary Team (IDT), which is the vehicle for all assessments and care planning IDT is composed of: The Participant and/or authorized representative Participant s designee PCP or designee Behavioral Health Professional (if one) Care Manager from FIDA plan Home attendant (or designee from agency) Representative from nursing home (if NH resident) IDT convenes in person or by phone at least every 6 months, and more frequently as needed Decisions reached by IDT through consensus become binding service authorizations of the FIDA plan N.Y. Dep t of Health, FIDA DEMONSTRATION REQUIREMENTS FOR ASSESSMENT, SERVICE PLANNING AND AUTHORIZATION, AND ONGOING CARE MANAGEMENT ( IDT Policy June 5, 2014) 2015 CSSNY 15

16 Transition/Continuity of care FIDA plans must allow participants to maintain ALL current providers and service levels, including doctors and prescription drugs, at the time of enrollment for at least the later of 90 days after enrollment, or until a care assessment has been completed by the FIDA plan. FIDA plan has 60 days to complete an assessment for people who transitioned from MLTC, and 30 days for new applicants who never had MLTC. FIDA plans must allow nursing home residents who were passively enrolled to stay in the same NH for the duration of the demonstration they cannot make them transfer to a different nursing home. The continuity period for behavioral health care will be for the duration of the episode of care, up to 2 years. FIDA 3-Way Contract [p.69] Integrated Appeal Process A unique and positive component of NYS s FIDA demonstration is that it will use one appeals process for all covered services (except Part D, which will remain separate) Consumer receives ONE notice not separate Medicare and Medicaid notices. Medical necessity standard is the more favorable of the two programs In a victory for advocates, Aid Continuing will be granted in ALL appeals even when MEDICARE services are denied, if the appeal is requested within 10 days of the notice. If timely requested, Aid Continuing will apply throughout the first three stages of the appeal process. FIDA 3-Way Contract 2.13 [p.129] 2015 CSSNY 16

17 Integrated Appeal Process Stages of Appeal There are 4 stages of appeal for all Medicare and Medicaid appeals. Aid Continuing applies through the 3rd stage. Initial appeal is to the Plan. If plan denies internal appeal, may appeal is to the State s integrated hearing officer who will hear both Medicare and Medicaid appeals (except for Part D). This is a new entity within OTDA. If hearing is lost, may appeal to the Medicare Appeals Council which will hear Medicaid issues as well as Medicare. Aid continuing applies if timely requested. Federal district court appeal. (NO automatic aid continuing) FIDA 3-Way Contract 2.13 [p.129] Info on FIDA FIDA 3-Way Contract: Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/ NewYorkContract.pdf CMS Enrollment & Disenrollment Guidance: Medicare-Medicaid-Coordination-Office/Downloads/MMPFinalEnrollGuidance.pdf CMS Appendix 5: State Specific FIDA Enrollment and Disenrollment Guidance for New York State: Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/NYApp5.pdf CMS-NY Memorandum of Understanding (MOU) Medicare-Medicaid-Coordination-Office/Downloads/NYMOU.pdf N.Y. Department of Health website for MRT 101 Duals Demonstration: Subscribe to MRT listserv Coalition to Protect the Rights Of New York s Dually Eligible (CPRNYDE aka Duals Coalition ) Independent Consumer Advocacy Network (ICAN) New York Medicaid Choice (enrollment broker) CSSNY 17

18 MANDATORY MANAGED CARE FOR NURSING HOME RESIDENTS What happens now? Now, MLTC is mandatory only for duals who need community-based long-term care o An MLTC member who needs NH placement would typically voluntarily disenroll, even though NH is in MLTC benefit package o Medicaid-onlies have long been required to join MMC plans, but are disenrolled from the plans if in a nursing home for more than 60 days 2015 CSSNY 18

19 Care Management for All (including Nursing Home Residents) Since September 2012, the State has required more and more Medicaid recipients receiving care in the community to enroll in Medicaid managed care plans Beginning February 2015,* Medicaid recipients in nursing homes will be required to enroll in managed care o Dual eligibles will be required to enroll in or stay enrolled in their MLTC plan for NH coverage o Medicaid-onlies will be required to enroll in or stay enrolled in their MMC plan for NH coverage Note: CMS granted official approval of this policy 12/31/2014. See /downloads/ny/ny-partnership-plan-ca.pdf * By to the MRT Listserv dated 12/29/2014, DOH delayed this initiative from January to February Who is affected? Medicaid eligible beneficiaries; Age 21 and over; In need of long term placement in a nursing facility.* *As defined by Social Security Act 1919(a)(1)(C) [42 U.S.C. 1396r] ( on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services (above the level of room and board) which can be made available to them only through institutional facilities, and is not primarily for the care and treatment of mental diseases. ) N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 1 (October 2014), available at nursing_home_transition_final_policy_paper.pdf 2015 CSSNY 19

20 Impact on Different Groups Grandfathered Nursing Home Residents o People already residing in a nursing home under fee-for-service Medicaid as of effective date MLTC members newly in permanent placement after effective date MMC members newly in permanent placement after effective date New applicants for Medicaid requiring nursing home placement Grandfathered Residents All current long term placed beneficiaries in a Medicaid certified skilled nursing facility (NH) prior to [February] 1, 2015 for Phase 1, [April] 1, 2015 for Phase 2, and July 1, 2015 for the upstate phase-in will remain in fee-for-service Medicaid and will not be required to enroll in a Managed Care Organization (MCO). N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 1 (October 2014). Dates in brackets revised based on MRT listserv dated 12/29/ CSSNY 20

21 Grandfathered Residents However, on October 1, 2015, grandfathered residents will no longer be excluded from managed care. This means that MLTC and MMC plans may market to such individuals, and they may choose to voluntarily enroll in managed care plans N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 1 (October 2014), as revised by MRT Listserv dated 12/29/2014. MLTC Members Needing NH After Effective Date Currently, MLTC members requiring permanent placement in nursing home are supposed to choose a NH in plan s network However, such members will no longer have the option of disenrolling to obtain fee-for-service Medicaid coverage for their nursing home stay Members may switch MLTC plans to gain access to preferred nursing home not in their current plan s network* No individual will be required to change nursing homes resulting from this transition NH and MLTC help individual apply for Institutional Medicaid * N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 14 (October 2014) CSSNY 21

22 MMC Members Needing NH After Effective Date Currently, MMC members requiring permanent placement are involuntarily disenrolled after 60 days New placements after the effective date will not be disenrolled o Long-term NH care is therefore being carved into the MMC benefit Must choose a NH in MMC plan s network Lock-in is suspended for MMC NH residents; they may switch plans to gain access to preferred nursing home not in their current plan s network* NH and MMC help individual apply for Institutional Medicaid * N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 14 (October 2014). New Medicaid Applicants Apply for Institutional Medicaid; NH can bill fee-forservice Medicaid retroactively for period prior to managed care enrollment Once Institutional Medicaid approved, individual has 60 days to select a plan If individual selects a plan that does not contract with his/her nursing home, he/she will have to move to a different nursing home If individual does not select a plan, NY Medicaid Choice will select one that does contract with the NH o MLTC for duals, MMC for non-duals N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 5-6 (October 2014) CSSNY 22

23 Phase-In Schedule Month Phase 1 February 1, 2015 Phase 2 April 1, 2015 Phase 3 July 1, 2015 October 1, 2015 County NYC Nassau, Suffolk, Westchester Albany, Allegany, Broome, Cattaraugus, Cayuga, Chautauqua, Chemung, Chenango, Clinton, Columbia, Cortland, Delaware, Dutchess, Erie, Essex, Franklin, Fulton, Genesee, Greene, Hamilton, Herkimer, Jefferson, Lewis, Livingston, Madison, Monroe, Montgomery, Niagara, Oneida, Onondaga, Ontario, Orange, Orleans, Oswego, Otsego, Putnam, Rensselaer, Rockland, St. Lawrence, Saratoga, Schenectady, Schoharie, Schuyler, Seneca, Steuben, Sullivan, Tioga, Tompkins, Ulster, Warren, Wayne, Washington, Wyoming, Yates Grandfathered NH residents in all counties will no longer be excluded from managed care (i.e., may voluntarily enroll) MRT Listserv dated 12/29/2014. Nursing Home Assessment Process for Managed Care Enrollees NH physician recommends permanent placement Plan reviews NH file and issues service authorization NH transmits LDSS-3559 to LDSS Member has appeal rights 2015 CSSNY 23

24 Network Requirements # of NHs Network minimum Manhattan 16 5 Brooklyn 42 8 Queens 55 8 Bronx 43 8 Staten Island 10 5 Nassau 35 8 Suffolk 43 8 Westchester 38 8 Monroe, Erie 5 Oneida, Dutchess, Onondaga, Albany 4 Broome, Niagara, Orange, Rockland, Rensselaer, Chautauqua, Schenectady, Ulster All other counties Specialty NHs (AIDS/ vent/ behavior) 3 2 unless only 1 exists 2 unless fewer exist Out-of-network Coverage Plans whose NH networks are inadequate, whether due to an insufficient number of contracts or an insufficient number of contracted NHs with available beds, will be required, upon member request, to permit members eligible for NH placement to receive services at a non-participating NH. N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 15 (October 2014) CSSNY 24

25 Rates Managed care plans are required to pay the Medicaid fee-for-service rate to all nursing homes in their networks for 3 years after the effective date in their region o Phase 1: 2/1/15 1/31/18 o Phase 2: 4/1/15 3/31/17 o Phase 3: 7/1/15 6/30/18 o May pay a different rate if mutually agreeable to plan and facility After this transition period, rates are left purely to negotiation between plans and facilities N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE at 2-3 (October 2014); dates revised in accordance with MRT listserv dated 12/29/2014. Institutional Medicaid All individuals in permanent placement must be eligible for Institutional Medicaid in order for nursing home stay to be covered, regardless of type of plan o 5-year look-back period o Penalty period for uncompensated transfers o Chronic care / Spousal budgeting Plan must pay facilities the fee-for-service rate during pendency of Institutional Medicaid Plan must recoup payments from facility if transfer penalty 2015 CSSNY 25

26 Resources on NH Managed Care N.Y. Dep t of Health, TRANSITION OF NURSING HOME BENEFIT AND POPULATION INTO MANAGED CARE (OHIP Policy Paper, October 2014) nursing_home_transition_final_policy_paper.pdf N.Y. Dep t of Health, TRANSITION OF NURSING HOME POPULATIONS AND BENEFITS TO MEDICAID MANAGED CARE (PowerPoint, March 20, 2014) transition_webinar_slides.pdf LTCCC Report on Mandatory MLTC in Nursing Homes (October 2013) DOH website for MRT NYHealthAccess.org article CSSNY 26