Providing Integrated Care for New York's Dual-Eligible Members · Department of Health 5 Why Align?...
Transcript of Providing Integrated Care for New York's Dual-Eligible Members · Department of Health 5 Why Align?...
Department of Health
Providing Integrated Care for New York’s Dual Eligible Members Stakeholder Session
August 2019
Department of Health
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Overview ❑ Current Landscape of New York’s Dual Population
❑ Benefits of Aligning Care for Duals
❑ Alignment Opportunities
❑ FIDA Updates
Department of Health
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Overview of New York’s Duals Programs New York’s Duals Programs
Medicaid Advantage
(MA)
Medicaid Advantage Plus
(MAP)
Programs for All Inclusive Care
for the Elderly (PACE) Partial Managed Long Term
Care
(MLTC) Integrated Plans
Authority 1115 Waiver 1115 Waiver Section 1934 Social Security Act 1115 Waiver
Age 18+ Voluntary 18+ Voluntary 55+ Voluntary
Voluntary, non-dual 18+
Voluntary, dual 18-20
Mandatory, dual 21+
# Enrollees 06/2019 5,175 15,977 5,776 235,945
(90% Dual, 212k)
Enrollment Criteria
Medicare Parts A&B, or enrolled
in Medicare Part C; Enrolled in
plan’s Medicare Advantage
Product
>120 days of LTSS, NH LOC
Medicare Part A&B, or enrolled in
Part C; Enrolled in plan’s
Medicare Advantage Plus
Product
>120 days LTSS, NH LOC
May be any or all of the following:
Medicare Part A; enrolled under Part B;
or eligible for Medicaid
Voluntary; >120 days LTSS, NH LOC
Mandatory; >120 days LTSS
LTSS Provided by Medicaid FFS Yes Yes Yes
# of Plans 3 7 9 27
There are also over 500,000 Full-Benefit Duals in Medicaid Fee For Service
Department of Health
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Where Are NY’s Duals Today? Opportunities for Continuity of Care
Low
Integration
Full
Integration
Data as of June 2018 Medicare
Placement Medicaid MCO Medicaid FFS % of Total
Medicare DSNP
with Medicaid
Contract Aligned*
22,623 0 3%
Medicare DSNP
with Medicaid
Contract Not
Aligned*
59,727 142,347 27%
Medicare
Advantage
Excluding DSNPs
42,755 68,115 15%
Medicare FFS 118,096 300,156 55%
Totals 243,201 510,618 100%
• Overall, only 3% of
membership is aligned
• There is a significant
population in
unaligned DSNPS that
present an opportunity
*Aligned is defined as being in the same plan for Medicaid and Medicare
Department of Health
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Why Align? • Simplification for Members to Improve Member Outcomes
• Aligned Clinical and Financial Incentives between Medicare and Medicaid
• Access to Stronger Care Coordination Model
Features of an Integrated Product ✓Continuity of care ✓Increased provider engagement
✓Person-centered care coordination ✓Ability to offer consumer incentives under Medicare
✓Integrated member services, member materials and ✓Coordinated communication with CMS
review process ✓Frailty adjuster
✓Unified process and review of marketing materials ✓Integrated data to better inform analytics, risk adjustment,
✓Coordinated appeals and grievances and rate setting
✓Aligned enrollment/disenrollment ✓Benefit package alignment
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What Happens Today as a Medicaid Member Becomes Dual by Turning 65?
Mainstream
Managed
Care Member
Medicaid
Medicaid
Medicare
Medicare
Choose MAP, PACE, MLTC
Partial, if no choice made,
enrolled to affiliated MLTC
Partial or other MLTC Partial
Medicare FFS or Advantage
Enrolled in FFS unless Member
chooses Medicaid Advantage
Medicare FFS or Advantage
Department of Health
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How Can We Better Align Duals?
The State can use CMS enrollment procedures for members as they
become dual eligible to align them into a MAP or MA plan
• Members would have the ability to opt out
• Members would still be able to select the plan of their choice
(PACE, MAP, MA, or MLTCP)
• Non LTSS Members will still have the choice to opt to FFS
Department of Health
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Member Timeline for Enrollment
Mainstream Enrollment
June 1st June 15th June 30th
Medicare Enrollment
Sept 30th
Members Move to MA/MAP Start
April May June July OctAug-Sept
This timeline reflects the overall movement for a member as they become dual eligible; the
State is working to operationalize this process
Step 3
Step 2
Step 0
Step 1
Step 5
Step 4
fi~:'K Department ~ATE of Health
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CMS Enrollment Procedure Process Step 5
Unless member opts out, member
enrolls into aligned product
Step 3 NYS shares
Step 0 Plan seeks approval
from CMS to begin
enrollment
procedure
Medicare eligibles
list with plans
90 Days Prior:
NYS notifies plan that
member will become
eligible in 90 days
Member becomes
Medicare eligible
Step 2 NYS identifies target
default population
(those most likely to
become dual: 87%
FPL)
120 Days Prior (or
earlier):
NYS works with CMS to
determine prospective
Medicare members
Step 1 NYS receives Medicare
eligible listing from CMS
60 Days Prior:
Plan notifies member that they
will be Medicare eligible in 60
days and enrolled in the
aligned product
Step 4 Plan to send member
notice
The State is working to operationalize this process
Department of Health
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Step 0: Plans Seek CMS Approval to Begin CMS Enrollment Procedure
Plan Application Support
• •
CMS provides support to States and Plans, including offering a Sample Model Notice (see next slide)
NYS is providing support to Plans in establishing the required data procedures and appropriately identifying the eligible
population
Subject to CMS approval, select Medicare Advantage organizations may automatically enroll newly certain
eligible Medicare beneficiaries into a dual eligible Medicare Advantage special needs plan (D-SNP) with member
ability to opt out
Individual Requirements
• Newly eligible for Medicare Advantage
• Currently enrolled in corresponding MMC (or under parent org)
• Will remain in Medicaid Managed Care upon Medicare enrollment
Plan Requirements
• Must have affiliated Medicaid Managed Care Products with DSNP
• Must demonstrate State approval and State agreement to provide necessary information for the Medicare Advantage plan to identify members in their Medicaid Managed Care who are in their Medicare Advantage initial coverage election period
• Minimum Medicare 3 star quality rating
• Obtain CMS approval through a proposal
• Must meet specific notice and timeline requirements
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<Ciy>, <Stale> <ZIP>
IMPORTANT: Your health and drug plan is changing.
Dear <Name ol MemDef>
Wea1ewritind 1oll!t you kn-aboutimportan1cha~s !oyourmedical andprescriptioodrug cove1aoe. As your Medicaid plan, we'd like to thank you lor your membefship in <Medicaid MCO Plan Name>, offered by <Parenl Oroanization Name>.
Because youwilbeeligiblellxMedicaresoon. <ParenlOryaniziltionName> wil automatica lly enroll you Into <D-SNP Name> !or you r Medicare benefits. This coverage will 11a n on <inu n tl!Ktive date a Pan A and B ellectiYe date>, the aame day your Medicare benefits ··~ You currently have <state~cific name for Meticaid progr,m> (Medicaid). <D-SNP name>, olle,ed by <paren10<9ani.:atiooname>. help,iyou1Medt::areand<Medicaidorstate-specific Medicaid name> benefit• wort. togethe,
If you don"! want <D-SNP name> lo provid<! your Medicare coverage. you can choose le yet yourMedicarecoverage !hroughanothefplanorlhrouyhOfiginalMedieare. ll youdon' lmake anothercholc<! by <in1endatebeloree~ c11'1e data>, you 'llbeenrolledwith <D-SNP name> 1tarting <in1enetrectlvedate>.
Your <1tate-1J)e(: ific name lor Medicaid p rog111m> cove111oe won'! change [lnsen M applicatle: <due to enrollment in <O-SNP name>, Original Medica•e or another Medicare health plan> You wil conlinoe lcget your <state..specificnameforMedicaidprogr1m> coveraoe through <Medic.aid MCO Plan Name>
You don '! Mve to do anything unlen yoo don't want to be au1omalically enroled in <O-SNP name>. llyoudon'tmakeanolherchoiceby<insert daybeforeeffecliYedate>, your new cove,*wilstarton cinsertellectrvedate>.
f or more information about yoor <D-SNP name> and the beriefits and seMCes you, new plan cove-s, or to lindoutil you can11iHsee your curren1 provider1in your newplan 1nd whetl>er your new plan coven an olyour pre1cription drug, , n l <O-SNP name> at <phorle oombe!>. TTY use,s should cal -<TTY number>-. We are open <dayslllours ol operation and, ~ different, TTY hoursoloperalion>
Medicare Managed Care Manual
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Department of Health
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Step 0: Plans Seek CMS Approval to Begin CMS Enrollment Procedure
Model Notice Medicare Manual Update
https://www.cms.gov/Medicare/Eligibility-and-https://www.integratedcareresourcecen
Enrollment/MedicareMangCareEligEnrol/Downloads/CY_201 ter.com/resource/default-enrollment-9_MA_Enrollment_and_Disenrollment_Guidance.pdf model-notice (Default Enrollment starts at section 40.1.4)
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Department of Health
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Next Steps For CMS Enrollment Procedures
• State establishes CMS Enrollment Procedure Design
• Plans begin process with CMS for Enrollment approval
• System changes occur to implement design
• Plans not currently eligible for CMS Enrollment Procedures to work with NYS and CMS on product line approval for November deadline
2019
• CMS approval of State Design and Plan application
• Plans not currently eligible for CMS Enrollment Procedures continue to work with NYS and CMS on plan approvals
• CMS Enrollment Procedure begins 2020
High Level Medicare Timeline
Intent to Apply
for Medicare
2021
Nov ‘19
Apply for Submit
Medicare 2021 Medicare Bid
Feb ‘20 Jun ‘20
Begin
New Medicare
MA/MAP Offering
Jan ‘21
®;.....__ ___________ _
Department of Health
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Path Forward For Integrated Members
Goals: Improve member outcome & experience through:
Strategies
Member choice and
continuity of care Member alignment and
integrated products
Partnering with plans,
providers, and
stakeholders to improve
outcomes
Item Enhance MAP through
integrated G&A
Medicare CMS Enrollment Procedure for MMC into Medicaid Advantage or
MAP
Enhance MAP and Medicaid Advantage
through integrated BH, including HARP benefits
Medicaid Advantage Choice/Opt-out for Non-
LTSS duals in Medicaid FFS today
~i:K Department ----- STATE of Health
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2019 FIDA Wind Down Timeline
October 2:
Members that have not
chosen to transition to
MAP will receive a
letter outlining their
enrollment choices
Late March (could be
earlier): Consistent with
CMS guidance, FIDA
plans may begin
marketing affiliated
CY2019 MAP to FIDA
enrollees
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December 31:
End of FIDA
December 20:
Any FIDA member that does not make a choice/is not
passively enrolled by this date will be auto-assigned to
the FIDA plan’s affiliated MLTC Partial Plan, Medicare
fee-for-service and a zero cost-share Part D plan
In July, there were 2,705 FIDA enrollees as compared
to 3,135 in January
2020
July: CMS releases the county-level
DOH released a
FIDA Phase-out
results of the three pronged test;
Plan for a 30 day
comment period
Mid August:
counties that did not pass
plans may focus marketing efforts on
DOH submits revised Phase-out
Plan to CMS
May 20: October: April:
CMS and DOH will send a Per the current FIDA Individuals in counties that
letter to FIDA plans in April MOU/three-way contract, pass the three pronged test
outlining the crosswalk individuals can no longer can begin to be passively
requirements and info FIDA opt into FIDA plan with an enrolled/cross walked into
plans will need to submit effective date 7/1/19 or affiliated MAP for 1/1/2020
later
Department of Health
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Future Discussions / Next Steps • Continued discussion with CMS on enrollment procedures
• Closing out FIDA Program
• We continue to welcome stakeholder feedback at [email protected]
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What Would Utilizing CMS Enrollment Procedures Look Like?
Mainstream
Managed
Care Member
Members have the ability to opt out of this enrollment
and retain full choice options
Medicaid
Through Enrollment Procedures,
Mainstream member would enroll
in the Medicaid Advantage Plus
product of their affiliated
Mainstream Plan
Medicare Enrolled in affiliated DSNP
Medicaid
Through Enrollment Procedures,
Mainstream member would enroll
in the Medicaid Advantage
product of the affiliated
Mainstream Plan
Medicare Enrolled in affiliated DSNP