Managed Long Term Care & Social Adult Day Care Presentation to the New York State Adult Day Services Association Mark Ustin Manatt Health September 30, 2016
Agenda 2 1 Background on Managed Long Term Care Today s Objectives 2 3 Medicaid Redesign Team Reforms Impact of Reforms on MLTC Relationship with Social Adult Day Care 4 Latest Issues Being Addressed by MLTC
Coalition of MLTC & PACE Plans 3 Twenty-two not-for-profit, provider-sponsored MLTC, PACE and MAP plans Provide coverage for more than 70% of the over 170,000 elderly and disabled individuals enrolled in MLTC, PACE and MAP statewide
Agenda 4 1 Background on Managed Long Term Care Today s Objectives
What is Managed Care? 5 Managed Care Organization receives capitated payment ($X per person per month), and uses those funds to pay for all medically necessary services within benefit packagefor all enrollees Simple in Theory, Complicated in Practice Assessment and care planning Network development and maintenance Enrollment/disenrollment Service authorizations & utilization review Care management Member services and grievance system Rate development Potential risk-sharing Claims management experience and capacity Marketing experience and capacity
NY s Managed Care Models for Long Term Care 6 Medicaid Managed Long Term Care MLTC Partially capitated Arranges and pays for only Medicaid-covered services, mostly long term care. Coordinates covered and non-covered services. Programs of All-Inclusive Care for the Elderly PACE Arranges and pays for all Medicaid and Medicare services (primary, acute and long term care). Services centered around adult day care center. Fully integrated Medicaid Advantage Plus MAP Fully integrated Arranges and pays for all Medicaid and Medicare services (primary, acute and long term care). Bridges MLTC model with Medicare Advantage plan.
Who is served by managed long term care? 7 MLTC MAP PACE Must be eligible for Medicaid Must have full Medicaid coverage and be eligible for Medicare Must be dual eligible (Medicaid & Medicare) or have Medicaid Must be age 18 or older Must be age 55 or older Must be capable of remaining in the community without jeopardizing health Must require care management and one or more long term care services for 120+ days Must be eligible for nursing home care
Long Term Care Plans in New York State 8 MLTC October 2015 August 2016 Total Enrollment: 128,288 159,575 PACE Total Enrollment: 5,493 5,524 MAP Total Enrollment: 6,210 6,055
Agenda 9 Today s Objectives 2 3 Medicaid Redesign Team Reforms
History of Medicaid Managed Care in New York 10 PHSP authorizing legislation enacted NYS legislature sets goal of enrolling 50% of Medicaid by 2000 Child Health Plus created Legislation passed imposing 9% surcharge on HMOs with too few Medicaid enrollees Family Health Plus created Mandatory MMC enrollment begins RFP issued for MMC providers Legislature intervened to raise plan rates Eligibility streamlining and simplification provisions enacted Facilitated enrollment program launched Mandatory MMC enrollment expanded to SSI populations Plan reserve requirements increased MMC reimbursement reforms implemented Mandatory MMC expanded to HIV/AIDS individuals 1985 1990 1995 2000 2005 2010 Further population and benefit (personal care, pharmacy) expansions Authorizing legislation enacted for various specific PACE and MLTC demonstration projects General MLTC authorizing legislation enacted DOH Interim Report on MLTC recommends increasing MLTC enrollment DOH Final Report on MLTC recommends further increasing MLTC enrollment Mandatory MLTC enrollment begins CCM Model established
Mandatory MLTC Implementation Plan 11 Sept. 2012-Feb. 2013: Phase I MLTC Enrollment Sept. 2012: All dual eligible cases new to service fitting the mandatory definition in NYC Sept. 2012: Personal care cases in New York county and begin personal care in Bronx County. October 2012: Continue personal care cases in New York and Bronx counties and begin Kings County. November 2012: Continue personal care and add consumer directed personal assistance cases in New York, Bronx, and Kings counties. Initiate CDPAP Citywide for new enrollees. December 2012: Continue personal care cases in New York, Bronx and Kings counties and begin Queens and Richmond counties. January 2013: Initiate enrollments citywide of non-personal care LTC programs February 2013 and until all people in service are enrolled: Citywide MLTC enrollment of all personal care and LTC programs June 2013: Phase III Mandatory MLTC enrollment of dually eligible community based long term care service recipients in Rockland and Orange counties Post June 2014: Phase VI Mandatory MLTC transition of previously excluded dual eligible groups: Nursing Home Transition and Diversion Waiver participants Traumatic Brain Injury Waiver participants Assisted Living Program participants June 2014: Phase V Mandatory MLTC enrollment of dually eligible community based long term care service recipients in other counties with capacity 2012 2013 2014 2012 2013 2014 Jan. 2013: Phase II Mandatory MLTC transition of dually eligible community based long term care service recipients in in Nassau, Suffolk and Westchester counties Dec. 2013: Phase IV Mandatory MLTC transition of dually eligible community based long term care service recipients in Albany, Erie, Onondaga, and Monroe counties
New Eligibility Standard: Theoretical 12 Department of Health Managed Long Term Care Guide You must join a Plan if: You have both Medicaid and Medicare You need home care, adult day health care, or other long term care for more than 120 days (four months) You are age 21 or older
New Eligibility Standard: Practical 13 Department of Health Website Am I eligible for managed long-term care? You are eligible to enroll in managed long-term care if you: have a chronic illness or disability that makes you eligible for services usually provided in a nursing home; are able to stay safely at home at the time you join the plan; are expected to need long-term care services for at least 120 days from the date you enroll; meet the age requirement of the plan (the age requirement for a PACE organization is 55 years old; for most other plans, the age requirement is 65 years old); live in the area served by the plan; have or are willing to change to a doctor who is willing to work with the plan; and have a way of paying that is accepted by the plan. All plans accept Medicaid. Some plans also accept Medicare and private pay.
Implications for SADC 14 MLTC Policy 13.03 (1/25/13): SADC is a covered benefit, but does NOT count for eligibility (only personal care services in the home) MLTC Policy 13.05 (2/28/13): SADC cannot represent an enrollee s complete plan of care
Agenda 15 Today s Objectives 3 Impact of Reforms on MLTC Relationship with Social Adult Day Care
Some Bad Press in April 2013 16 Plans accused of questionable arrangements with social adult day care facilities Unregulated facilities Questionable services Potentially improper incentives Dubious eligibility Enrollment was suspended in one large plan, and a series of investigations were initiated
DOH Regulatory Response 17 Medicaid Director Letter 4/26/13: SADC cannot represent the primary service in a plan of care All plans required to immediately reassess enrollees receiving SADC OMIG audits pending Reminder that plans may not offer materials, financial gain or service incentives as an inducement to enroll No marketing permitted at, or referrals permitted from, SADC sites
More New DOH Policy Statements 18 MLTC Policy 13.11 (5/8/13): If, upon reassessment, an enrollee does not need or refuses CBLTC services (e.g. in-home personal care), should be disenrolled Fee-for-service Medicaid will not pay for SADC Plans must formally credential all providers, including SADC programs, at least every three years All contracted SADC programs must meet SOFA standards
More New DOH Policy Statements 19 MLTC Policy 13.14 (5/30/13): No required or recommended service mix or ratio of CBLTC to SADC services MLTC Policy 13.15 (6/10/13): Individuals who only require housekeeping do not meet MLTC eligibility requirement
Credentialing of SADC Programs 20 DOH circulated list of suspect programs (including some that met SOFA standards and some that did not) Plans argued that imposing individual responsibility for SADC program credentialing was too burdensome MLTC Policy 15.01 (5/8/15): Requires new annual certification process for any SADC programs contracting with MLTCPs MLTCPs must ensure contracted SADC programs have certification MLTCs still required to conduct annual site inspections of SADC programs
Legislative Responses New York City Council 21 Local Law 9 of 2015 (1/17/15): SOFA Standards Applicable to all NYC SADC programs Registration All SADC programs required to register with the NYC Department for the Aging (DFTA) Civil Penalties DFTA is required to establish civil penalties for failure to register, and non-compliance with state standards Ombudsperson DFTA is required to establish an Ombudsperson Signage All SADC programs required to post a sign providing contact information for the Ombudsperson
Legislative Responses State Legislature 22 S.3923/A.5352 (Savino/Cymbrowitz): SOFA Standards Applicable to all SADC programs statewide SOFA Report Due by 12/31/16 Status - Delivered to Governor on 11/10/15 VETO: Rather than burden one agency with a wide-ranging directive for which it does not have the funds to implement successfully, I am instructing SOFA and the Department of Health to work collaboratively with all interested stakeholders to develop a regulatory framework that ensures the needs of all SADS recipients are being met on a statewide, uniform basis.
Investigations 23 Attorney General s Medicaid Fraud Control Unit Office of Medicaid Inspector General
Investigations 24 Attorney General s Medicaid Fraud ontrol Unit Office of Medicaid Inspector General A.G. Schneiderman Announces $47 Million Settlement With Centerlight Healthcare For Fraudulently Using Social Day Care Centers To Enroll Ineligible Members 2-year agreement with independent compliance monitor
Investigations 25 Attorney General s Medicaid Fraud Control Unit Office of Medicaid Inspector General 2016-17 Work Plan: In conjunction with the Medicaid Fraud Control Unit and the New York City Buildings Department, OMIG will continue its investigations of social adult day care centers. OMIG will also coordinate with DOH and the New York State Office for the Aging (NYSOFA) to implement the state certification process and align this process with the existing registration process that exists for New York City facilities. Additionally, OMIG will continue to verify that social adult day care centers have documentation required to maintain certification, and will continue to meet quarterly with Managed Long term Care plans and the New York City Department for the Aging to coordinate efforts to identify ongoing issues. OMIG will review MLTC enrollment records to determine if MLTC plans have properly determined eligibility for enrollment and whether they have provided proper care management to selected MLTC members
Agenda 26 2 Today s Objectives 4 Latest Issues Being Addressed by MLTC
Value Based Purchasing Part 1 27 NY using more innovative ways to get dollars to providers VBP-QIP program has been designed to transition struggling facilities to more value-based arrangements and in doing so, these facilities get infusions of cash from the State through plans (and federal match) State also using plans to distribute dollars to PPSs for program development (in order to get federal match)
Value Based Purchasing Part 2 28 One key issue is how to reconcile the State s three decades of reliance on managed care with the very expansive role envisioned by PPS s, not only through the waiver time period, but thereafter Overall goal is 80-90% of managed care payments to be some form of VBP: Level 1: Upside only model (only shared savings; no risk) Level 2: Includes downside risks in addition to the shared savings Level 3: Fully capitated payments
Fully Integrated Duals Advantage Program (FIDA) 29 As part of Medicaid reform, with the support of CMS, the State established FIDA program to fully coordinate care for dual eligibles in single program Expires in 2017 Design and implementation challenges, lack of provider engagement and support, concerns about rate sufficiency, decreasing plan participation and extremely low enrollment Plans are recommending incorporating some elements of program into other duals models (especially MAP), but discontinuing FIDA itself
Fair Hearings 30 A provocative study earlier this year by Medicaid Matters New York and the National Academy of Elder Law Attorneys, NY Chapter identified a significant increase in the number of appeals of MLTC services determinations in recent years However, increase can probably be attributable, at least in part, to: Overall increase in MLTC enrollment Change in rule requiring exhaustion of internal utilization review procedures Greater regulatory and judicial scrutiny of care management determinations substantially diminishes the extent to which they are able to act like managed care
Minimum Wage 31 The State s overall objective of utilizing managed care to reduce costs and to enhance quality has been complicated by the extent to which workforce/union objectives have mandated living wage/minimum wage enhancements Have been implemented by mandating almost to the penny what MLTCs must pay. Federal overtime and related requirements have also placed plans and providers at greater compliance risk and have resulted in substantially higher costs. In short, state telling plans both what to cover and what price to offer
Changes in Key DOH Personnel 32 November 2015 September 2016 Mark Director of the Division Special Assistant Kissinger of Long Term Care to the Commissioner for Long Term Care Andrew VNSNY Choice Director of the Division Segal of Long Term Care
Questions? 33 Mark Ustin mustin@manatt.com (518) 431-6795 136 State Street, Suite 300 Albany, New York 12207
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