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 HealthManaged Care Concepts – in Dual Eligible plans• Full Capitation – Rate covers all Medicare & Medicaid

services (PACE & Medicaid Advantage Plus)• Partial Capitation – Rate covers only certain

Medicaid 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 beneficiariesoAge 21 and overoRequire 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 noticeo 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/StatusMLTC – 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 Mainstream Medicaid 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

Mainstream managed 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 8/2011 STATEWIDE/ 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 all Medicare & 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 staff

o 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?