page 1

Medicaid Managed Care Program Changesand Future Initiatives

April 27, 2011NYAPRS 7th Annual Executive Seminar on System Transformation

page 2

Administrative Actions Affecting Premiums

Reduce Profit From 3% to 1%(Proposal #6)

Effective 4/1/11 Reduces surplus built into MMC and FHP rates Amendment to Part 98 will be made to reduce contingent

reserve requirement as it relates to MMC and FHP lines of business for 2011 and 2012, and tightens requirements for equity withdrawals

Reduce Trend Factor 1.7%(Proposal #8) Effective 4/1/11

Reduces projected 4/1/11 rate increase by 1.7% by reducing trend factors for MMC and FHP

page 3

Eliminate Direct Marketing(Proposal #10)

Effective 4/1/11

Contract Amendment to prohibit plans from engaging in marketing activities; plans can continue to do FE

Continue working with the industry to develop the most equitable way to administer the reduction as long as target is met.

page 4

Bundle Pharmacy into MMC(Proposal #11)

Effective 10/1/11

Brings pharmacy benefit into MC benefit package better aligning the overall benefit package

Modest increases to existing co-pays for brand, generic, and over-the-counter medications

Will work with the industry to promote a smooth transition

page 5

Behavioral Health BHO & Integrated Models(Proposal #93)

Manages FFS and current “carved out” behavioral health services for all managed care enrollees

Regional BHO’s responsible for medical management and coordination of behavioral health services

Future years risk models include integrated delivery systems

page 6

Benefit limits/changes

Effective 4/1/11

Footwear (Proposal #30) Limited to children, diabetics, or use in conjunction with a lower limb orthotic brace

Compression Stockings (Proposal #42) Limited to pregnancy or treatment of open wounds only

Tobacco Cessation (Proposal #55) Expands coverage to all women (not only pregnant

women) and men 6 counseling sessions within any 12 month contiguous

period

page 7

Benefit limits/changes

Effective 9/1/11 SBIRT (Proposal #83) Expands screening,

intervention, and referral to treatment for alcohol/drug use beyond the ER setting to primary health care settings

Effective 10/1/11 PT/OT & Speech (Proposal #34) Limit 20 visits in

12 month period, similar to current limits for FHP

page 8

Population and Benefit Expansion, Access to Services, and Consumer Rights

(Proposal #1458)

Expand Managed Care Enrollment for non-dual eligibles and modify mainstream benefit package

Access to Benefits and Consumer Protections

Streamline Managed Care Eligibility Process

page 9

Expand Enrollment & Modify Benefit Package

Expands enrollment of many previously exempt & excluded populations over 3 years:

Year One – program ready Enroll new populations

Exclusions – Recipient Restriction Exemptions – HIV upstate, non-SSI SPMI/SED,

primary care/pregnant w/non-network provider, temp out of district, language barrier, geographic accessibility, chronic illness limit

Added benefit Personal care

page 10

Expand Enrollment & Modify Benefit Package

Year Two Enroll new populations

Exclusions – Infants<1200 gr., LTHHCP where capacity, RRSY adolescents, nursing home residents

Exemptions – LTHHCP look-alikes, ESRD, CIDP, homeless

Added benefit Nursing home services

page 11

Expand Enrollment & Modify Benefit Package

Year Three Enroll new populations

Exclusions- eligible for Medicaid buy-in for Working Disabled, residents of State operated psychiatric centers*, blind or disabled children living apart from parents for 30 days or more, institutional foster care children*

Exemptions- residents of ICF/MR or ICF/DD and persons with needs similar to these residents, Nursing Home Diversion and transition waiver, resident of Long Term Chemical Dependence programs*, Bridges to Health foster care waiver program*, non-institutionalized foster care children, Medicaid Home and Community-based Services Waiver recipients and individuals with needs similar to the waiver recipients, Care at Home recipients and individuals with needs similar to Care at Home recipients

*enrollment contingent upon decisions regarding the benefit package

page 12

Access to Benefits and Consumer Protections

Builds on current policies/procedures in place Ensure adequate information for more chronic

populations being enrolled How to access services How to navigate managed care systems

Ensure plans have active language translation, including TTY/TTD

Compliance with ADA Ensure MCOs & providers are adequately trained in

covered benefits (ex. DME) & consistent w/ FFS Modify Benefit Denial notices

page 13

Streamline Managed Care Enrollment Process

Mandates earlier choice of managed care plan during the eligibility process For new applications

Choice must be made during the application process Similar to enrollment process for FHPlus

For persons newly targeted for mandatory enrollment allows for 30 days to choose plan If plan not chosen, current auto assignment algorithm followed

page 14

Accelerate State Assumption of Medicaid Program (Proposal #141)

November 2010 Report to Governor for State takeover of Medicaid Administrative Functions

Consolidate health plan contracts for Medicaid Managed Care statewide

LDSS no longer to be involved in enrolling eligibles into Managed Long Term Care plans

page 15

Mandatory Enrollment in MLTC and other Care Coordination Models (Proposal #90)

Mandatory Enrollment Begins – April 2012 Elimination of NH Certifiable Requirement Elimination of Designation Requirement Provision for MLTC Partial Cap Expansion Health Home Conversion Establish Workgroup

page 16

Mandatory Initiative for April 2012

1115 Waiver approval needed from CMS Require all dual eligibles who need community-

based long term care services for more than 120 days to enroll in Managed Long Term Care or other approved care coordination models.

Elimination of Nursing Home Level of Care Requirement upon Enrollment Impact on Partials, MAP, PACE Establish Documentation Requirements

Model Contract Amendments MLTC and Care Coordination Model

page 17

Modify Role of LDSS in MLTC Enrollment (Proposal #141)

MLTC Enrollment Criteria remains the same until April 2012

Pre Enrollment Approval by LDSS will be phased out for Partial Cap and MAP by Sept, 2011 Applicability to PACE will be explored with CMS

Model Contract Amendment Required Revisions to plan materials must be processed Training of Enrollment Broker/other Local

Entities

page 18

Dual Eligible Initiative(Proposal #101)

Anticipate receipt of 18 month planning contract with CMS for “State Demonstrations to Integrate Care for Dual Eligible Individuals”

Conduct analysis of Medicare / Medicaid data on Duals

Engage Stakeholders Develop Demonstration Proposal and submit to

CMS for implementation in Year 3