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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

legal@selfhelp.net

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

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ber

Oct

obe

r

Dec

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r

Janu

ar y20

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Aug

ust

Nov

embe

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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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