Medicaid Redesign in New York State:

Managed Long Term Care in Nursing Homes

AcronymsDual 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 certainMedicaid services – MLTC package of long termcare services

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 waivero NHTDW – Nursing Home Transition & Diversion Waivero 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

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

From 2006 to 2011 alone New York State Medicaid spending increased by 14 Percent to $52.9B

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

The Issue: Fee for Service vs Managed CareFee 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).

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.

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.

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.

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)

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)

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

4 Big Changes – Managed Care & LTCChange 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 MainstreamMedicaid 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

Mainstreammanaged 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 8/2011STATEWIDE/ 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 allMedicare & Medicaid services

11/13 CMS reached“Memorandum of Understanding” with SDOH. CMS now doing “Readiness review” of 25 FIDA plans.

Fully Integrated DualsAdvantage 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.

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 staffo Admissions, Social Work, Case Management, Billing

• Educating Familieso NY Medicaid Choice

(http://www.nymedicaidchoice.com/)

Impact on YOU!• Contract negotiation with MCO’s

• Admission and discharge

practices

• Case Management – skilled staff

required!

• Communication

Questions?