While at Good Shepherd Fairview Home my final project for my internship was to make a presentation to give to leadership about the Medicaid Redesign in New York State. I did research about Governor Cuomo and the Medicaid redesign team that he instated to redesign New York’s Medicaid program in January 2011 to ensure that it was sustainable. The main goal of the presentation was to inform the staff about how things will change when managed care organizations will be present.
2. Acronyms
Dual Eligible = Someone who has Medicare & Medicaid
TYPES OF PLANS/ Agencies
• MLTC – Managed Long Term Care
• MA – Medicare Advantage OR Medicaid Advantage
• MAP – Medicaid Advantage Plus
• PACE – Program for All-Inclusive Care for the Elderly
• LDSS – Local Dept. of Social Services/ Medicaid program
• DOH – NYS Dept. of Health
Managed Care Concepts – in Dual Eligible plans
• Full Capitation – Rate covers all Medicare & Medicaid
services (PACE & Medicaid Advantage Plus)
• Partial Capitation – Rate covers only certain
Medicaid services – MLTC package of long term
care services
3. Continued…
TYPES OF SERVICES
• CBLTC - Community-Based Long-Term Care services
• LTC – Long Term Care generally also known as
o LTSS – Long Term Services & Supports
• PCS or PCA – Personal care services – Personal Care Aide
• CDPAP or CDPAS – Consumer Directed Personal Assistance
Program
• CHHA – Certified Home Health Agency
• ADHC – Adult Day Health Care (medical model)
o SAD or SADC – Social Adult Day Care
• PDN – Private Duty Nursing
“Waiver” programs – Home & Community Based Services (HCBS)
o Lombardi – Long Term Home Health Care Program
o TBI – Traumatic Brain Injury waiver
o NHTDW – Nursing Home Transition & Diversion Waiver
o OPWDD – Office of Persons with Developmental
Disabilities Waiver
DOH – NYS Dept. of Health “GIS” – type of DOH directive
DSS or LDSS – local Dept. of Social Services
4. The Issue
• The U.S. spends more on health care - both
per capita and as percentage of gross
domestic product (GDP) than other nations
do.
• The US spends 16% of it’s GDP on healthcare
–nearly double all other countries
• New York specifically spent nearly double
the national average per recipient
• Unless this is changed the Medicaid
program in New York will no longer be
sustainable
5. From 2006 to 2011 alone New York State Medicaid
spending increased by 14 Percent to $52.9B
6. The Solution: Redesigning New York’s Medicaid
Program
• Governor Cuomo created the MRT to redesign
New York’s Medicaid program in January 2011
to ensure that it was sustainable.
• One overarching theme of the redesign team
proposals is to move all Medicaid recipients
from Fee for Service reimbursement to
Managed Care.
• Broome County Social Services is NOW a
Mandatory Medicaid Managed Care County.
o Managed Care enrollment is currently mandatory for Community
Medicaid and Family Health Plus eligible individuals in Broome
County
7. The Issue: Fee for Service vs Managed Care
Fee for Service (FFS) Managed Care
Who does Medicare or Medicaid
pay?
Pays each provider fee for each
service rendered
Pays flat monthly fee (capitation)
to insurance plan
Who does provider bill? Provider bills Medicare or
Medicaid directly
Bills the managed care plan,
which pays from a monthly
capitation rate from Medicare or
Medicaid
Providers available Any provider who accepts the
insurance (e.g. Medicare)
Only providers in the insurance
plan’s network
Permission needed for services? Sometimes. In Medicaid, need
approval for personal care,
CDPAP, etc. but not for all
medical care.
Often. Plan may require
authorization to see specialists,
or for many services. May not
go out of network.
Policy – incentive to give too
much/ too little care?
Incentive to bill for unneces-sary
care. But offset when
authorization needed for
services like Medicaid personal
care.
Plan has incentive to DENY
services, and keep part of
capitation rate for profit.
What package of services is
available?
Original Medicare = all Medicare
services.
Package of services may be
“partial” (MLTC) or full (PACE =
all Medicare & Medicaid
services).
8. What is Managed Care?
• Managed-care organizations (MCOs) serve as an
integrating mechanism because they combine the
insurance and service delivery functions of health
care.
• Managed care delivers coordinated health care
services and supports through a network of
providers.
o Attempting to fix the disconnect of all the necessary
services one needs for a better quality of life.
9. Vision for Health Care
System Redesign
• Improving the quality of care by focusing on
patient-centered care, timeliness, efficiency and
equity.
• Improving health by addressing root causes of poor
health e.g., poor nutrition, physical inactivity, and
substance use disorders.
• Bend the Medicaid cost curve by reducing per
capita costs
• Ensure access to quality care for all Medicaid
members.
10. Delivery System Reform
Incentive Payments (DSRIP)
• MRT Waiver – the waiver allows the state to reinvest
over a five-year period $8 billion of the $17.1 billion
in federal savings generated by MRT reforms
• The DSRIP program promotes community-level
collaborations and focuses on system reform.
o Their main goal is to achieve a 25% reduction in avoidable
hospital use over five years.
• Safety net providers will be required to collaborate
to implement innovative projects focusing on
system transformation, clinical improvement and
population health improvement.
11. A prospective enrollee has a choice of three
Managed Long Term Care Models:
• Partially Capitated Managed LTC (Medicaid)
Benefit package is long term care and ancillary
services including home care, unlimited nursing home
care
• Program of All-Inclusive Care for the Elderly (PACE)
(Medicare and/or Medicaid)
Benefit package includes all medically necessary
services – primary, acute and long term care ( Must be
nursing home eligible)
• Medicaid Advantage Plus (MAP) (Medicare and
Medicaid)
Benefit package includes primary, acute and long term
care services (Must be nursing home eligible, also
excludes some specialized mental health services)
12. MLTC Enrollment
• Who is required to enroll in MLTC?
oDual Eligible Medicaid beneficiaries
oAge 21 and over
oRequire long term care services for
more than 120 days
• Community Based Long Term Care Services
(i.e. Personal Care, Nursing, ADHC, Therapy)
13. MLTC Enrollment
• Applicant must choose a plan and a
primary care provider (PCP) within 60 days
for MLTC.
o Mandatory Notice - sixty day choice period
begins with this notice
o Auto Assignment - if the consumer does not
choose a plan within 60 days, one will be auto-
assigned for them using the state’s approved
algorithm
• 9 month “lock-in” period begins after first 90
days of enrollment and applies with every
new enrollment
15. 4 Big Changes – Managed Care & LTC
Change Description Fed Approval/Status
MLTC – Managed
Long Term Care
Dual eligibles age 21+ access to most
home care services is solely through
an MLTC, PACE or Medicaid
Advantage Plus plan in NYC & 9
other counties
CMS approved 1115
Waiver expansion 9/2012,
started NYC/Metro area,
rolling out Statewide
2013-14
Nursing home care
“carved into”
managed care
package
Both Dual eligibles in MLTC plans
and non-duals in Mainstream
Medicaid managed care plans must
access nursing home care through
plan, rather than fee for service.
CMS approval pending for
June 2014 start roll-out
downstate, then Dec. 2014
Upstate
Mainstream
managed care –
carve-in PCS,
CDPAP, PDN
Non-dual eligibles STATEWIDE in
mainstream Medicaid managed care
must get personal care, CDPAP,
private duty nursing thru MC plans
CMS approved for PCS/
CDPAP eff 8/2011
STATEWIDE/ nursing
home will start 6/2014
FIDA – Fully
Integrated Dual
Advantage
Dual Eligible MLTC members in
NYC, Long Island & Westchester will
be “passively enrolled” into FULL
CAPITA-TION FIDA managed care
plans that control all Medicare &
Medicaid services
11/13 CMS reached
“Memorandum of
Understanding” with
SDOH. CMS now doing
“Readiness review” of 25
FIDA plans.
16. Fully Integrated Duals
Advantage Program (FIDA)
• FIDA plans are fully capitated plans similar to
Medicaid Advantage Plus. They will control all:
o Medicaid services including long term care now covered by
MLTC plans PLUS other Medicaid services NOT covered by MLTC)
o Medicare services – ALL primary, acute, emergency, behavioral
health, long-term care
• Who will be affected by this?
o Adult dual eligibles – who are receiving or applying for either:
MLTC, MAP or PACE services (125,000 people) OR
Nursing home care (55,000 people), but
EXCLUDES – people in TBI, NHTDW, OPWDD waivers, hospice,
Assisted Living Program.
• When?
o Roll-out begins Oct. 1, 2014 (pushed back 6 months on Jan. 16,
2014). Demo ends Dec. 2017.
17. Nursing Home Transition Issues
• Contracts with MCO’s – getting them
and agreeing on terms
• Partnering with plans and hospitals
• Understanding the facility’s role vs. the
MCO’s role in managing care
• Educating staff
o Admissions, Social Work, Case Management, Billing
• Educating Families
o NY Medicaid Choice
(http://www.nymedicaidchoice.com/)
18. Impact on YOU!
• Contract negotiation with MCO’s
• Admission and discharge
practices
• Case Management – skilled staff
required!
• Communication
Managed care delivers coordinated health care services and supports through a network of providers.
Attempting to fix the disconnect of all the necessary services one needs for a better quality of life.
Managed care works like a health care supermarket to deliver all of your Medicaid benefits through one organization.
Fee for Service
Medicaid and traditional Medicare
Patient uses any provider
Care not coordinated, duplicative services
Managed Care
Costs are predictable
Services and specialists are coordinated based on comprehensive plan of care
Managed care delivers coordinated health care services and supports through a network of providers.
Attempting to fix the disconnect of all the necessary services one needs for a better quality of life.
Managed care works like a health care supermarket to deliver all of your Medicaid benefits through one organization.
Improve coordination and cost-effectiveness of acute and LTC services for Medicaid-only beneficiaries
Acute care services include physicians, hospitals, Rx drugs, clinics
LTC services include personal care assistance, home health, HCBS waivers, other community services, nursing facility services, services for people with developmental disabilities
transform the state's health care system
bend the Medicaid cost curve
ensure access to quality care for all Medicaid members.
On April 14, 2014 Governor Andrew M. Cuomo announced that New York has finalized terms and conditions with the federal government for a waiver that will allow the state to reinvest $8 billion in federal savings generated by Medicaid Redesign Team (MRT) reforms.
the special terms and conditions also commit the state to comprehensive payment reform and continuing New York's effort to effectively manage its Medicaid program within the confines of the Medicaid Global Spending Cap
The transition of the nursing home benefit and population into Medicaid managed continues to be delayed. Phase 1 has been pushed from to June 1, 2014 to August 1, 2014 and now October 1, 2014. At this point in time the transition of the rest of the state is April 1,2015. The federal Centers for Medicare and Medicaid Services has yet to approve the State’s transition plan for the nursing home benefit and population.
the transition of the nursing home benefit and population into Medicaid managed care in the New York City, Long Island and Westchester regions has been delayed from August 1, 2014 to October 1, 2014.
the federal Centers for Medicare and Medicaid Services has yet to approve the State’s transition plan for the nursing home benefit and population
assumption at this point is that the transition in the rest of state would tentatively begin on April 1, 2015.
for those without Medicare, into mainstream managed care plans
Capitated –a fixed, pre-arranged monthly payment/ rate received by a physician, clinic or hospital per patient enrolled in a health plan
Voluntary “opt in” for those dual eligible over the age of 21 who need Medicaid long-term care for more than 120 days
Managed Care for Dual Eligibles
Mandatory Managed Long Term Care (MLTC)
FIDA
Federal and State want to control costs of dual eligibles.
Coordinate care
Government wants to save money, transfer risk to insurance plans
In each district, NYSDOH in partnership with NY Medicaid Choice will provide education to providers and stakeholders on the change in the delivery of LTC services.
Discharge Practices
Change perception of who is dischargeable
Discharge begins on admission
Work with Plan on target discharge date (Not under your control anymore)
Discharge planning more involved
Coordinating with multiple Plans to identify approved providers
Case Management
Dedicated resources
Experienced
Proactive
Excellent communication skills (documentation comes from your EMR)
Work with Business Office and Administration to identify and resolve payment issues timely
Communcation
Staff
Interdisiplinary
Real-time (EMR, e-mail, secure texting)
Families
Educate about plans, benefits (or lack of), and who is paying when
Difference between your decisions and the insurers (discharge date, services authorized)
Vendors
Patient’s primary payers/plans, who to bill