Managed Long Term Care & Social Adult Day Care Presentation to - - PowerPoint PPT Presentation

Managed Long Term Care & Social Adult Day Care

Presentation to the New York State Adult Day Services Association

September 30, 2016 Mark Ustin Manatt Health

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Agenda

Background on Managed Long Term Care

Today’s Objectives

Medicaid Redesign Team Reforms Impact of Reforms on MLTC Relationship with Social Adult Day Care

1 2 3 4

Latest Issues Being Addressed by MLTC

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Coalition of MLTC & PACE Plans

• 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

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Agenda

Background on Managed Long Term Care

Today’s Objectives

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Assessment and care planning Enrollment/disenrollment Care management Potential risk-sharing Rate development Claims management experience and capacity Network development and maintenance Marketing experience and capacity Service authorizations & utilization review Member services and grievance system

Simple in Theory, Complicated in Practice 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

What is Managed Care?

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NY’s Managed Care Models for Long Term Care

Arranges and pays for only Medicaid-covered services, mostly long term care. Coordinates covered and non-covered services.

Medicaid Managed Long Term Care

MLTC

Partially capitated

Arranges and pays for all Medicaid and Medicare services (primary, acute and long term care). Services centered around adult day care center.

PACE

Programs of All-Inclusive Care for the Elderly

Fully integrated

Arranges and pays for all Medicaid and Medicare services (primary, acute and long term care). Bridges MLTC model with Medicare Advantage plan.

Medicaid Advantage Plus

MAP

Fully integrated

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Who is served by managed long term care?

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

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Long Term Care Plans in New York State

October 2015 August 2016

Total Enrollment: 128,288 159,575 Total Enrollment: 5,493 5,524 Total Enrollment: 6,210 6,055

MLTC PACE MAP

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Agenda

Today’s Objectives

Medicaid Redesign Team Reforms

2 3

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1985 1990 1995 2000 2005 2010

PHSP authorizing legislation enacted NYS legislature sets goal of enrolling 50%

• f Medicaid by 2000

Legislation passed imposing 9% surcharge on HMOs with too few Medicaid enrollees RFP issued for MMC providers Mandatory MMC enrollment begins Family Health Plus created Eligibility streamlining and simplification provisions enacted Facilitated enrollment program launched Mandatory MMC enrollment expanded to SSI populations MMC reimbursement reforms implemented Mandatory MMC expanded to HIV/AIDS individuals Legislature intervened to raise plan rates Plan reserve requirements increased Further population and benefit (personal care, pharmacy) expansions Child Health Plus created General MLTC authorizing legislation enacted Authorizing legislation enacted for various specific PACE and MLTC demonstration projects Mandatory MLTC enrollment begins DOH Interim Report on MLTC recommends increasing MLTC enrollment DOH Final Report on MLTC recommends further increasing MLTC enrollment CCM Model established

History of Medicaid Managed Care in New York

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2012 2013 2014

Mandatory MLTC Implementation Plan

• 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

• Jan. 2013:
• Phase II – Mandatory MLTC transition of

dually eligible community based long term care service recipients in in Nassau, Suffolk and Westchester counties

June 2013:

• Phase III – Mandatory MLTC

enrollment of dually eligible community based long term care service recipients in Rockland and Orange counties

• Dec. 2013:
• Phase IV – Mandatory MLTC transition
• f dually eligible community based

long term care service recipients in Albany, Erie, Onondaga, and Monroe counties

June 2014:

• Phase V – Mandatory MLTC

enrollment of dually eligible community based long term care service recipients in “other counties with capacity”

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

2012 2013 2014

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New Eligibility Standard: Theoretical 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

Department of Health Managed Long Term Care Guide

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New Eligibility Standard: Practical

• 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.

Department of Health Website

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Implications for SADC

• 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

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Agenda

Today’s Objectives

Impact of Reforms on MLTC Relationship with Social Adult Day Care

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Some Bad Press in April 2013

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

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DOH Regulatory Response

• 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 Medicaid Director Letter 4/26/13:

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More New DOH Policy Statements

• 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

MLTC Policy 13.11 (5/8/13):

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More New DOH Policy Statements

• No required or recommended service mix or ratio of CBLTC

to SADC services MLTC Policy 13.14 (5/30/13):

• Individuals who only require housekeeping do not meet

MLTC eligibility requirement MLTC Policy 13.15 (6/10/13):

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Credentialing of SADC Programs

• 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

• 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 MLTC Policy 15.01 (5/8/15):

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Legislative Responses – New York City Council

• 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 Local Law 9 of 2015 (1/17/15):

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Legislative Responses – State Legislature

• SOFA Standards – Applicable to all SADC programs

statewide

• SOFA Report – Due by 12/31/16
• Status - Delivered to Governor on 11/10/15

S.3923/A.5352 (Savino/Cymbrowitz): 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.”

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Investigations

• Attorney General’s Medicaid

Fraud Control Unit

• Office of Medicaid Inspector

General

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Investigations

• 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

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Investigations

• 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

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Agenda

Today’s Objectives

2 4

Latest Issues Being Addressed by MLTC

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Value Based Purchasing – Part 1

• 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)

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Value Based Purchasing – Part 2

• 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

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Fully Integrated Duals Advantage Program (FIDA)

• 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

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Fair Hearings

• 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

• f 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

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Minimum Wage

• 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

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Changes in Key DOH Personnel

November 2015 September 2016

Mark Director of the Division Special Assistant Kissinger

• f Long Term Care

to the Commissioner for Long Term Care Andrew VNSNY Choice Director of the Division Segal

• f Long Term Care

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Questions?

Mark Ustin mustin@manatt.com (518) 431-6795 136 State Street, Suite 300 Albany, New York 12207

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