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Transcript of 1 Managed Long-Term Care Understanding the Changes to Medicaid Home Care in New York State Evelyn...
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Managed Long-Term Care Understanding the Changes to Medicaid Home Care in New York State
Evelyn Frank Legal Resources Program
David Silva, Ass’t. Director & Valerie Bogart, Director
(212) 971-7658
http://nyhealthaccess.org
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What is Managed Long Term Care?
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What is Medicaid Managed Long-Term Care?
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Medicaid Managed (Care) Long-Term Care
The public health insurance program for the poor, operated by the State
A type of private health insurance company paid a fixed amount per capita to authorize and pay for all covered services (“capitation”)
Home careAdult day carePhysical therapyNursing homeEtc.
Remember when there wasonly ONE Medicare?
We’ve been here before
Original Medicare
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Why are we talking about this?The privatization of Medicaid home care in New York state due to Medicaid Redesign.
Old System New System
Old System
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New System
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New bureaucracy
◦ No more CASA staff (mixed blessing)
◦ Less accountability (if that’s even possible)
New incentives
◦ Fixed payment (“capitation”) per person per month creates financial incentive to contain costs
New service delivery system
◦ Providers of long-term care services must contract with private plans, not government agency
So what?
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The government wants to end Fee-for-Service in both Medicaid and Medicare. 1. FEE FOR SERVICE – like American Express card
◦ Original Medicare or regular Medicaid◦ Client uses any provider that accepts Medicare or Medicaid –
not limited to any network◦ Provider bills insurance (Medicare or Medicaid) directly◦ Some services require “prior approval” but many don’t – if doctor
prescribes, insurance pays2. MANAGED CARE – like having a MACY’s card only
◦ Medicare Advantage or mainstream Medicaid Managed Care◦ Providers must be in-network, services & specialist referrals
must be approved by a Primary Care Provider (PCP)◦ Provider bills managed care company, not Medicare or Medicaid.
If client went out of network, provider may not get paid
Managed Care vs. Fee for Service
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What changed?
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MLTC will be mandatoryOver the next year, all recipients of Medicaid home care services will be required to enroll in MLTC plans
Only affects dual eligibles (Medicare and Medicaid) Mandatory enrollment will be phased in gradually from
July 2012 through 2013, starting with NYC home attendant cases
Clients have 60 days from date of notice to select an MLTC plan or one will be chosen for them at random
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Affected Clients
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Dual eligibles (must have Medicare & Medicaid); and Age 21 or older; and Receiving Community-Based Long-Term Care services for
>120 days in a calendar year◦ Personal care (PCA/home attendant)◦ Certified Home Health Aide (CHHA)◦ Adult Day Care◦ Lombardi Waiver (Long-Term Home Health Care Services)◦ Private-Duty Nursing◦ Consumer-Directed Personal Assistance Program
(CDPAP)
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What will happen to them?
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These individuals will be required to join a Managed Long-Term Care plan to receive their Medicaid home care benefits
Clients will receive notices from NY Medicaid Choice stating that they must select a plan or they will be randomly assigned to one
Clients will be given a list of plans from which to choose, which include:◦ MLTC plans (aka “partial-cap”)◦ Programs of All-inclusive Care for the Elderly (PACEs)◦ Medicaid Advantage Plus (MAP)
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Map of Managed Care
Medicare Medicaid
Home Care Services
Medicare Advantage
Mainstream MMC
Partial-Cap MLTC
Medicaid Advantage
PACE
MAP
Personal Care carve-in
Dental, vision, hearing, etc.
Might have to change
doctors/hospitals!
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Client plan options
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MLTC *MLTC *
MAPMAP
PACEPACE
Duals receiving
CBLTC
Duals receiving
CBLTC
* Client will be assigned to MLTC if no selection made.
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1. Most managed long term care plans are “partially-capitated” – the benefit package is solely Medicaid-only long-term care services and limited other health services – not all primary care. List follows.
2. “Full Capitation” – includes all Medicaid AND Medicare services – primary care, acute, hospital, behavioral and long term care services in the benefit package. This means the client might have to change all their doctors/hospitals!
a. Program of All-Inclusive Care for the Elderly (PACE)
b. Medicaid Advantage Plus (MAP)
Two general types of MLTC plans in NYS
Current EnrollmentPartial-cap MLTC Plans NYC 5-2012
Name TOTAL 44,527
VNS CHOICE 10,524
GUILDNET 7,149
ELDERSERVE 5,858
ELDERPLAN (HomeFirst) 5,523
CenterLight (formerly CCM SELECT) 4,152
SENIOR HEALTH PARTNERS (HealthFirst) 3,823
WELLCARE 2,300
INDEPENDENCE CARE SYSTEMS 2,159
AMERIGROUP 1,485
HHH CHOICES (Bronx only) 1,339
Fidelis 5
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Home care:◦ Personal Care (home attendant)◦ Consumer-Directed Personal Assistance Program
(CDPAP)◦ Home Health Aide, PT, OT (CHHA Personal Care)
Adult day care, PERS, home-delivered meals Medical equipment, supplies, prostheses, orthotics, hearing
aids, eyeglasses, respiratory therapy Home modifications Podiatry, Audiology, Dental, Optometry Non-emergency medical transportation Nursing home
Services authorized by MLTC
Above are partial capitation only.PACE, MAPlus include more primary and acute medical services
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Letters from NY Medicaid Choice Pre-notice 6/2012 to some Manhattan residents – “MLTC
coming” - copy attached First Notice – Enrollment Packet
◦ Notice stating that individual must enroll in an MLTC plan within 60 days or they will be randomly auto-assigned. Includes a list of plans and educational material.
Second Notice◦ 30 days after 1st notice
Third Notice◦ 45 days after 1st notice; includes name of plan to which individual
will be auto-assigned Fourth Notice
◦ 60 days after 1st notice; informing individual of auto-assignment
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When?Ju
ly
Sep
tem
ber
Oct
obe
r
Dec
embe
r
Janu
ar y20
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Aug
ust
Nov
embe
r
NY Medicaid Choice sends first letters to Manhattan PCA recipients
Manhattan non-responders will be auto-enrolled.Begin sending letters to Bronx PCA recipients.
Letters go to Brooklyn PCA recipients
Letters go to Queens and Staten Island PCA recipients
NY: 60 daysBronx: 60 days
Kings: 60 days
Letters to Lombardi, CHHA, adult day, LPN
Q & SI: 60 days
What about CHHA & Lombardi in NYC? Only “long-term” CHHA clients are required to enroll in
MLTC Short-term clients can continue to receive CHHA services
fee-for-service Once a client enrolls in an MLTC plan, if they require HHA,
PT, OT, visiting nurse, etc. it must be provided by their MLTC plan (under contract with a LHCSA)
Long-term CHHA clients won’t receive auto-enrollment letters until January 2013 at the earliest
Lombardi – will be auto-enrolled in NYC in Jan. 2013 or later
Adult day and private duty nursing – also Jan. 2013 or later
Phase II
◦ Nassau, Suffolk and Westchester Counties – Anticipated January 2013
Phase III
◦ Rockland and Orange Counties – Anticipated June 2013
Phase IV
◦ Albany, Erie, Onondaga and Monroe Counties – Anticipated December 2013.
Phase V
◦ Other counties with capacity – Anticipated June 2014.
Implementation outside NYC
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DOH, “Mandatory Managed Long Term Care Enrollment Plan” posted athttp://www.health.ny.gov/health_care/medicaid/redesign/docs/2012-02-26_mltc_enrollment_plan.pdf
Phase VI
◦ Previously excluded dual eligible groups contingent upon development of appropriate programs:
Nursing Home Transition and Diversion waiver participants;
Traumatic Brain Injury waiver participants;
Nursing home residents;
Assisted Living Program participants;
Dual eligibles that do not require community based long term care services.
Implementation Schedule
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DOH, “Mandatory Managed Long Term Care Enrollment Plan” posted athttp://www.health.ny.gov/health_care/medicaid/redesign/docs/2012-02-26_mltc_enrollment_plan.pdf
Law requires MLTC plan to provide previous level of
services for 30 days pending its new assessment After the 30 days, State will allow plans to reduce
services Must give written notice and right to a hearing – but not
AID CONTINUING beyond end of prior authorization
period
◦ Advocates think this violates the Due Process clause of the
U.S. Constitution.
Transition
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Advocacy Concerns
Meeting Needs of High Hour Clients.◦ Capitation Incentive to Give Low hours – Many
MLTC plans in NYC have done heavy marketing to enroll large numbers of low-hour clients. They receive same capitation rate for all clients.
◦ High-need MLTC client can’t transfer to Personal Care/home attendant program. Now, MLTC will be mandatory – will have to fight plan for more hours. Standards for 24-hour care unclear.
Advocacy Concerns
See more info at http://wnylc.com/health/entry/114/
Consumer appeals/ fair hearings – rights not as clear as in personal care/home attendant program.
Standards for authorizing care – will MLTC plans be required to follow rules established through litigation, i.e.,
◦ can’t use task-based-assessment when client has 24-hour needs (“Mayer-III”)
◦ must provide adequate hours to ensure safe performance of ADLs (NYS DOH GIS 03 MA/003
◦ non-self-directing people eligible if someone can direct care who need not live with them (92-ADM-49)(Illegal “Back-up” requirement).
◦ Cannot terminate services when hospitalized
Advocacy Concerns con’d
See http://wnylc.com/health/entry/114/ & http://wnylc.com/health/entry/7/
Advocacy ConcernsExcess Nursing Home Usage
◦ MLTC benefit package includes nursing home care◦ Wide variation among MLTC plans in rate of NH
admission◦ People with high-hour needs, or who are difficult to
serve due to dementia, etc. are at risk of NH placementReporting and State Oversight
◦ With budget cuts, does DOH have staff to monitor plans adequately, collect and analyze data on quality and monitor avoidable institutionalization?
◦ Plans must be required to monitor and report outcomes, quality measures, nursing home placement and
Advocacy Concerns Case Management – will it be more than limiting hours? Will it
actually coordinate medical care, ensure access to transportation,
other MLTC services?
Disability literacy – understanding needs of people with
disabilities, eg. Wheelchair fitting & authorization, “dignity of risk”.
Capacity – Plans now have 37,000 members, will more than
double their enrollment from July – Dec. 2012. Can they do it?
Medicaid applications and recerts – role of CASAs? How
ensure home care not disrupted when glitches in recertifications?
See more in advocates letter to DOH, 5/2011*
http://www.health.ny.gov/health_care/managed_care/appextension/ (under Public Comments)
Advocacy concerns - CDPAP Consumer Directed Personal Assistance Program – 2012
state budget requires all MLTC and Medicaid Advantage Plus
plans to offer this option.
Until now, only one MLTC plan has voluntarily offered
CDPAP (ICS in NYC)
CDPAP has inherent conflict with “managed care” – as it is
not a medical model. Unclear whether MLTC plans, which
are inherently medical/nursing model, will understand
CDPAP and honor consumer choices
See more concerns in advocates letter to DOH 05/2011, 3/12
and 12/11
See more on CDPAP at http://wnylc.com/health/entry/40/
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The End
Check out http://nyhealthaccess.org for updates!
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