Fully Integrated Duals Advantage (FIDA) Provider Outreach and Education Event September 30, 2015 Joseph Shunk, Interim FIDA Project Director New York State Department of Health (DOH) Office of Health Insurance Programs Division of Long Term Care Melissa Seeley, Technical Director Centers for Medicare and Medicaid Services (CMS) Medicare-Medicaid Coordination Office
2 Learning Objectives: By the end of this activity, learners should be able to: 1. Recognize what the Fully Integrated Duals Advantage (FIDA) program is and how it operates (including benefit package, eligibility criteria, enrollment process); 2. Identify the roles and responsibilities of providers and how they are paid under FIDA; 3. Identify the benefits of integrated care and the Interdisciplinary Team (IDT) for beneficiaries and providers; and 4. Identify how to structure an IDT and specific examples of how integrated care and the IDTs have helped beneficiaries.
3 What is FIDA? The Fully Integrated Duals Advantage (FIDA) program is a partnership between the Centers for Medicare and Medicaid Services (CMS) and the New York State Department of Health (DOH). Through FIDA, certain dual eligible individuals (Medicaid and Medicare) will be enrolled into fully-integrated managed care plans. FIDA is operational in New York City and Nassau County and the Demonstration period runs from January 2015 to December 2017. Timing of Westchester and Suffolk County is to be determined, but it will be some time after January 1, 2016. There are 18 FIDA Plans in New York City and Nassau County.
4 Vision for FIDA Improve the Participant s experience in accessing care; Deliver person-centered care that promotes coordination missing from today s fragmented system; Promote independence in the community; Improve quality through improvements in care and coordination; Develop a more easily navigable and simplified system of services for individuals and their families; Ensure access to needed services and incorporate Participant protections; Meet robust network adequacy standards for both Medicaid and Medicare; and Evaluate data on access, outcomes and experience to ensure Participants receive higher quality care.
5 Key Highlights of FIDA Builds off of Managed Long Term Care (MLTC); Provides a comprehensive benefit package; Provides a Care Manager and an Interdisciplinary Team (IDT); Integrates the grievance and appeal process with continuation of benefits pending appeal through appeal to Medicare Appeals Council (excluding Part D); Utilizes an independent, enrollment broker, NY Medicaid Choice (i.e., Maximus), to assist with enrollment and options counseling; and Includes the Participant Ombudsman: Independent Consumer Advocacy Network (ICAN).
6 Who is Eligible for FIDA? Eligible individuals: Are age 21 or older at time of enrollment; Are entitled to benefits under Medicare Part A, enrolled under Part B, eligible to enroll in Part D, and receiving full Medicaid benefits; and Reside in New York City, Long Island, or Westchester County. And must meet one of the following: Require more than 120 days of community-based long term services and supports (LTSS); or Are Nursing Facility Clinically Eligible and not receiving facility-based LTSS (i.e., New to Service ); or Are eligible for the Nursing Home Transition and Diversion Waiver program.
7 FIDA Enrollment There are two types of enrollment: Opt-in Enrollment, which is initiated by an individual. Passive Enrollment, which is enrollment by the State which the individual can decline by opting out. Individuals who are eligible for FIDA and enrolled in a MLTC Plan will convert in place to the FIDA Plan offered by the parent organization of their MLTC Plan. Participants may opt out of passive enrollment or disenroll at any time. Those who opt out or disenroll will continue to receive Medicaid services through the MLTC program and have a choice of Original Medicare or Medicare Advantage and a prescription drug plan. Participants who have opted out may re-join the program at any time.
8 FIDA Plans FIDA Plan Name Aetna Better Health FIDA Plan AgeWell New York FIDA AlphaCare Signature FIDA Plan HealthPlus Amerigroup FIDA Plan CenterLight Healthcare FIDA Plan Elderplan FIDA Total Care FIDA Care Complete Fidelis Care FIDA Plan GuildNet Gold Plus FIDA Plan FIDA Plan Name Healthfirst AbsoluteCare FIDA Plan ICS Community Care Plus FIDA MMP MetroPlus FIDA Plan North Shore-LIJ FIDA LiveWell RiverSpring FIDA Plan SWH Whole Health FIDA VillageCareMAX Full Advantage FIDA Plan VNSNY Choice FIDA Complete WellCare Advocate Complete FIDA
9 Level of Integration of Medicare Advantage Plans D-SNP: Dual Eligible Special Needs Plan *MA-PD: Medicare Advantage Prescription Drug Plan **MMP: Medicare-Medicaid Plan. A FIDA Plan is an MMP, which includes LTSS and behavioral health.
10 Why Should Individuals Join FIDA? FIDA provides full Medicare and Medicaid coverage, long term care services, Part D and Medicaid drugs, and additional benefits from a single, integrated managed care plan. Under one plan, FIDA covers all the benefits that the individual may receive through their MLTC Plan, Original Medicare or their Medicare Advantage Plan, and their Medicare Part D Plan. FIDA covers additional services most of which are not currently available through MLTC Plans, for example: Home and community support services (e.g., respite) Mobile mental health treatment Peer mentoring Positive behavioral interventions and support Substance abuse services Wellness counseling FIDA provides a Care Manager who can schedule doctor s appointments, arrange transportation and help them get their medicine. FIDA coordinates all services (including inpatient and outpatient) and encourages participant, caregivers, and providers to make care decision together via an IDT.
11 Why Should Individuals Join FIDA? Pay NO deductibles, premiums, or copayments/coinsurance to the Plan; Need NO referrals to see specialists; Use one phone number to call the Plan for all questions regarding their benefits; Use one ID card to receive all of their benefits; and Have the right to leave FIDA at any time and for any reason. If they decide to disenroll from FIDA, they will continue to receive all of their Medicaid benefits through the MLTC Plan and all of their Medicare benefits through Original Medicare, or a Medicare Advantage Plan, and a Part D plan.
12 Why Should Providers Participate in FIDA? FIDA will allow Providers to collaborate with other providers as part of a care team. The care team develops a single, customized care plan to address all of the Participant s specific needs. FIDA will help improve patient/member compliance with medication, scheduled office visits, treatment modalities, etc. FIDA will save Providers time, as the FIDA Care Manager will document a Participant s care plan, and any changes to it; help Participants schedule appointments and arrange for transportation to them; and keep Providers informed about services their Participants receive. FIDA may help decrease avoidable hospitalizations by offering Providers more opportunities to speak with your Participants and the other members of the care team to make sure they understand and follow the goals of their care plans. FIDA Care Managers will be responsible for ensuring access to and compliance with follow-up care. FIDA will streamline the administrative claims processing, since there is one billing process and one payer (the FIDA Plan) for both Medicare and Medicaid services.
13 If a Provider Joins a FIDA Plan Be willing to participate in the IDT, if requested by the Participant; Make sure their information is current with each of the Plans with whom they contract; and Take FIDA Overview Training, which includes IDTs and care planning, except for the following provider types: Anesthesiology Pathology subspecialties Sports Medicine Radiology subspecialties DME Emergency Medicine Critical Care Medicine Environmental Supports Home Delivered Meals Laboratory Genetics Pediatrics Emergency Transportation (Ambulance) Non Emergency Transportation Hearing Aid Dispenser PERS (Personal Emergency Response) Participating Providers who are IDT members must also take other trainings: Cultural Competency Behavioral Health Disability Recovery and Wellness
14 If a Provider Joins a FIDA Plan cont. Consolidated training for all providers across the 18 FIDA Plans is available via web-based portal at: https://fida.resourcesforintegratedcare.com Training completed via the portal is automatically tracked and providers receive email confirmation as record of completion. Questions about the training on the Lewin Portal should be sent to RIC@Lewin.org. More information about provider training can be found at: https://www.health.ny.gov/health_care/medicaid/redesign/provider_training_qa.htm
15 Not in a FIDA Plan Network Out-Of-Network (OON) rules: The Plan or the IDT can approve a Provider who is OON, when necessary, to meet the needs of the Participant. Participants must have access to all Providers, including Non-Participating Providers, all authorized services, and pre-existing service plans, including prescription drugs, for at least 90 days or until the care plan is finalized and implemented, whichever is later. Plans must provide OON Providers with information on how to apply to become Participating Provider.
16 Payments FIDA Plans receive payments for Medicare Parts A/B and Part D from CMS and Medicaid payment from State in a capitated payment. Payment rates to Plans are based on estimates of what Medicare and Medicaid would have spent on enrollees in absence of FIDA. Plans receive a monthly integrated capitation payment and providers bill the FIDA Plan directly for all services rather than Medicare or MLTC. Balance billing of Participants is prohibited. Unless a contract between a provider and health plan specifies otherwise, there is no need for a provider to differentiate whether the services are covered through Medicare or Medicaid.
17 Payments to Non-Participating Providers For covered items and services that are part of traditional Medicare (i.e., Medicare FFS) benefit package: FIDA Plans pay at least the lesser of the providers charges or the Medicare FFS rate, regardless of the setting and type of care for authorized OON services. For nursing facility services part of traditional Medicaid benefit package: FIDA Plans pay the Medicaid FFS rate until at least December 31, 2015. For covered items and services that are part of the traditional Medicaid benefit package: FIDA Plans shall pay any State Office of Mental Health or State Office of Alcoholism and Substance Abuse Services licensed or certified Provider of behavioral health services at least the applicable Medicaid FFS rate for a period of not more than 2 years.
18 FIDA Care Coordination and the IDT Each Participant has his/her own Interdisciplinary Team that engages with the Participant in care planning and care coordination. For each Participant, FIDA Plans will support an IDT, led by a care manager to ensure the integration of the Participant s medical, behavioral health, substance use, community based or facility-based LTSS, and social needs. The IDT is person-centered, built on the Participant s specific preferences and needs, and delivers services with transparency, individualization, accessibility, respect, linguistic and cultural competence, and dignity. The FIDA Plan Care Manager is the lead, facilitates all IDT activities, and conducts ongoing care management activities. The IDT develops a Person-Centered Service Plan (PCSP), which is a written document housed in the Participant s care management record. The PCSP outlines all the services the Participant needs and when, how, and by whom those services will be provided to the Participant. The Care Manager is responsible for coordinating, arranging, and ensuring receipt of these services.
19 IDT Members A Participant s IDT must be made up of: The Participant or, in the case of incapacity, an authorized representative; The Participant s designee(s), if desired by the Participant; A Primary Care Provider (PCP) or a designee (i.e., NP or RN) with clinical experience from the PCP s practice who has knowledge of the Participant s needs; A Behavioral Health Professional, if there is one, or a designee with clinical experience from the professional s Behavioral Health practice who has knowledge of the Participant s needs; The FIDA Plan Care Manager; The Participant s Home Care Aide(s), or a designee with clinical experience from the home care agency who has knowledge of the Participant s needs, if desired by the Participant; The Participant s Nursing Facility Representative, who is a clinical professional, if receiving Nursing Facility care; and Other Providers as requested by the Participant or designee; or as recommended by the IDT. The RN who completed the Participant s Assessment, if approved by the Participant or designee.
20 IDT Member Responsibilities Each member of the IDT is responsible for: Actively participating in the IDT service planning and care management process; Attending meetings - whether in person, or by means of real time, two-way communication, such as by telephone or videoconference; Regularly informing the IDT of the medical, functional, and psychosocial condition of each Participant; and Documenting changes of a Participant's condition in the Providers' own medical record for the Participant, consistent with policies established by the FIDA Plan.
21 Establishing the IDT Each Participant will actively participate in the IDT which will address their medical, Behavioral Health, LTSS, and social needs. FIDA Plans should identify IDT members and start scheduling IDTs as soon as possible. Plans are currently required to convene IDTs within 30 days of Participants having a Comprehensive Assessment by an RN. DOH and CMS are considering extending this timeframe to 60 days. IDT members may be added and removed as needs arise and care has ended. The IDT must convene routinely, and no more than six months from the previous IDT meeting. These meetings may occur more frequently after trigger events.
22 IDT Authorization The IDT develops the PCSP and as a whole is responsible for making coverage determinations and authorizes services. After the PCSP is developed by the IDT, care decisions contain therein act as service authorizations for six months or the duration of the care plan. Service authorizations made by the IDT may not be modified by the FIDA Plan; unless modified pursuant to the decision of a Participant appeal. In between IDT meetings, the FIDA Plan (i.e., utilization management) may authorize services. The Participant may appeal any IDT decision, regardless of whether the Participant agreed at the time of the IDT meeting. IDT approval is not required for drugs. However, the IDT may authorize drugs as part of the care plan development process and, at a minimum, is required to discuss and incorporate a list of medications in use by the Participant within the care plan.
23 Continuity of Care FIDA Plans must allow Participants to maintain current providers even if not in FIDA Plan s network and service levels, including prescription drugs, for at least 90 days or until a PCSP is finalized and implemented, whichever is later. Exceptions to 90-Day Continuity of Care: Existing behavioral health service providers must be maintained for up to 24 months. For nursing facility services, FIDA Plans must allow Participants to maintain current providers for the duration of the Demonstration. If the IDT or FIDA Plan approves the Participant to see an out-of-network provider.
24 IDT Policy Updates Effective September 15, 2015, DOH and CMS issued the following IDT policy updates, based on feedback from FIDA Plans, Providers, and other stakeholders: Acceptance of electronic signatures and verbal approvals of care plans (i.e., PCSPs). Clarification that the IDT may convene without the PCP or designee, if the PCP agrees to review and approve the PCSP or have his/her designee do so after the IDT meeting. This option requires 3 documented attempts by the FIDA Plan to engage the PCP. The Care Manager circulates proposed PCSP changes from the PCP to other IDT members for approval. If there is not approval, the FIDA Plan shall use the UM process to approve any new services immediately following this IDT meeting while concurrently sharing the PCSP with the PCP for review and approval. Clarification that the FIDA Plan Care Manager will coordinate the FIDA service planning process with existing service planning processes (e.g., nursing facilities, providers whose conditions of participation require service planning).
25 More Information FIDA Provider FAQ: www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare- Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/NYProviderFAQ.pdf FIDA Pharmacy Provider FAQ: www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare- Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/NYPharmacyProviderFAQ.pdf Joint Rate-Setting Process FAQ: www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare- Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/JointRateSettingProcess.pdf General Information: www.cms.gov/medicare-medicaid-coordination/medicare-and-medicaid-coordination/medicare- Medicaid-Coordination-Office/ www.health.ny.gov/health_care/medicaid/redesign/fida/ https://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm
Questions? 26