Mark Kissinger Division of Long Term Care

Office of Health Insurance Programs

May 22, 2012

Plan released

Care Management for All is a key element of the future

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To give one entity responsibility for assessing and arranging services and care management toward: ◦ Improving outcomes for enrollees Prevent or delay decline due to chronic conditions Reduce the need for acute care services

◦ Improving satisfaction with life status for enrollees and caregivers

◦ Producing savings for payers

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An entity designated under 4403-f

Has a certificate of authority (COA) under

Article 44 to: ◦ Meet member needs for health and long term care services ◦ Receive capitated payment(s) for benefit package services

(per member/month)

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Adults (Age 18 and older) Eligible for nursing home level of care using the

Semi-Annual Assessment of Members (SAAM) – UAS in the future

Able to live safely in the community upon enrollment

In need of the long term care services of the plan for at least 120 days (nursing, therapy or aide services in the home; or adult day health care; or social day care if used as a substitute for personal care services)

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Cannot be concurrently enrolled in a HCBS waiver program (LTHHCP, NHTD, TBI); OMRDD day treatment; or hospice at time of MLTC enrollment

Can be enrolled in Medicare Advantage Plan concurrently but not Medicaid Managed Care

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Three MLTC models 1. Partially Capitated Managed LTC

2. Program of All-Inclusive Care for the Elderly (PACE)

3. Medicaid Advantage Plus (MAP)

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◦ Capitated for some Medicaid services only

◦ Benefit package is long term care and ancillary services including

home care, unlimited nursing home care

◦ Primary and acute care covered by FFS Medicare or Medicaid

◦ 14 plans offer this product

◦ April 2012, enrollment = 45,417 increasing every day

◦ Census ranges from 124 to 10,524

◦ DOH had a moratorium on the development or expansion of new partially capitated plans between 2006 - 2011

Medically necessary services including:

Care management Home care Nursing home care (unlimited) PERS OT, PT, Speech therapies (in-

home and outpatient) Medical and social day care

Dental Optometry Podiatry Audiology Transportation DME Social and environmental

supports Plan pays for Medicare

cost sharing on nursing home, DME, outpatient therapies

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◦ Federal program type for Medicare and Medicaid at State option

◦ Capitated for all Medicare and Medicaid services ◦ Most integrated of the MLTC models ◦ Day center / clinic based ◦ Provider network usually small ◦ Benefit package includes all medically necessary services –

primary, acute and long term care ◦ 8 plans now offer this product ◦ April 2012 enrollment = 4,314 ◦ Range = 81 – 3,074 ◦ 1New PACE program is under development

All medically necessary

services including: Inpatient hospital Nursing home (unlimited) PT, OT, Speech Prescription drugs Physician (primary care

and specialist) Home care Transportation Laboratory and X-ray Emergency transportation

Medical supplies and equipment

Dental care Vision care Podiatry Social day care Mental health Social and environmental

supports

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o Capitated for Medicare and Medicaid under two separate contracts (Federal and State)

o All plans must cover the Combined Medicare and Medicaid Benefit Package as defined by DOH

o Plans must meet both Medicare and Medicaid requirements

o Challenge is to have this appear seamless to the member

o 8 plans now offer this product

o April 2012 census = 1,875

o Range = 45-633

All Medicare services

All Medicaid services with the exception of some specialized mental health services

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2011 Budget legislation requires: ◦ All dual eligibles who are - ◦ Age 21 and older and - ◦ In need of community-based long term care

services for more than 120 days…..

Must enroll in a MLTCP or other Care Coordination Model

Duals between 18 and 21 remain voluntary

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1115 Waiver approval needed from CMS before we can start

Eliminates the need to score as Nursing Home eligible upon enrollment

Definition of community-based long term care services includes: ◦ Personal care services ◦ Home health services ◦ Adult day health care ◦ Private duty nursing

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Other models that meet “guidelines specified by the Commissioner that support coordination and integration of services”

Guidelines must address: ◦ Requirements in 4403-f (3)(a-i) ◦ Payment methods the ensure provider accountability for cost effective

quality outcomes

Includes Long Term Home Health Care Programs that meet the guidelines

Medicaid Redesign Team Workgroup worked over the summer and fall to develop Principles to be applied to CCMs

Guidelines that incorporate those principles were posted on DOH website on November 15, 2011. They can be found at: ◦ http://www.health.ny.gov/health_care/medicaid/redesign/managed_ltc_

workgroup.htm

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Working with HRA to determine most effective, efficient way to transition people ◦ Will not take place all at once By program By borough

Consumer Choice preferred but Auto Assignment for those

who do not

Must ensure continuity of care plan and service provider

Significant educational component for people new to system and transitioning

Enrollment of those receiving Consumer Directed Personal Assistance services will not begin until September, 2012

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Several groups are not eligible to enroll in MLTC or care coordination models until program features and reimbursement rates are developed

These include people in: ◦ Traumatic Brain Injury (TBI) Waiver ◦ Nursing Home Transition and Diversion (NHTD) Waiver ◦ Assisted Living Program (ALP) ◦ Office of People with Developmental Disabilities (OPWDD)

Wavier

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There must be a choice of plans in urban

areas, at least one in rural counties

Upstate expansion will be county by county, as sufficient MLTC plan and CCM model capacity is developed

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New law eliminates previous requirement for designation by Senate, Assembly or Commissioner or Health before applying

Applications for new entities or new lines of business and expansions have been posted on DOH website: ◦ http://nyhealth.gov/facilities/long_term_care/managed_long_term_care.htm

Requires: ◦ Adequate legal structure ◦ Identification of service area and target population (including any

special populations) ◦ Character and competence review ◦ Contracted network review ◦ Description of care management model, grievance system

◦ Demonstration of financial capability and capitalization

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Statute allows up to 75 MLTC Certificates of Authority ◦ 42 COAs for new MLTCs can be approved

Applicants approved for a COA enter into a contract with DOH

A readiness review is conducted before operations begin

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Mandatory Population: Dual eligible, aged 21 and over, receiving community based long term care services for over 120 days, excluding the following for now:

• Nursing Home Transition and Diversion waiver participants; • Traumatic Brain Injury waiver participants; • Nursing home residents; • Assisted Living Program participants; • Dual eligible that do not require community based long term care

services.

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In addition to those who must enroll in a Managed Long Term Care Plan or Care Coordination Model, the following people may voluntarily enroll:

• Dual eligible, 18-21, in need of community based long term care services for over 120 days.

• Dual eligible age 18-21 and non-dual eligible age 18 and older assessed as nursing home eligible.

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People New to Service

• Beginning July 1, 2012 - Any dual eligible case new to service, fitting the mandatory definition in any New York City county will be identified for enrollment and referred to the Enrollment Broker for action.

• Enrollment Broker will provide with educational material, list of plans/CCMs, answer questions and provide assistance contacting a plan if requested.

• Plan/CCM will conduct assessment to determine if eligible for community based long term care.

• Plan/CCM transmits enrollment to Enrollment Broker

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Enrollment will be phased-in by service type by borough by zip code in batches. People will be given 60 days to choose a plan according to the following schedule:

• July 1, 2012: Begin personal care* cases in New York County.

• August 1, 2012: Continue personal care cases in New York County.

• September, 2012: Continue personal care cases in New York County and begin personal care in Bronx County; and begin consumer directed personal assistance program cases in New York and Bronx counties.

• October, 2012: Continue personal care and consumer directed personal assistance program cases in New York and Bronx counties and begin Kings County.

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• November 2012: Continue personal care and consumer directed personal assistance program cases in New York, Bronx and Kings counties

• December 2012: Continue personal care and consumer directed personal assistance program cases in New York, Bronx and Kings Counties and begin Queens and Richmond counties

• January 2013: Initiate enrollments citywide of long term home health care program, home health over 120 days, adult day health care program and private duty nursing cases not enrolled under personal care case activity.

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• February 2013 and until all people in service are enrolled: Personal care, consumer directed personal assistance program, long term home health care program, home health over 120 days, adult day health care program and private duty nursing cases in New York, Bronx, Kings, Queens and Richmond Counties

*Individuals receiving personal care while enrolled in Medicaid Advantage will begin MLTC/CCM enrollment in January, 2013.

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• As plan capacity is established, dually eligible community based long term care service recipients will be enrolled as follows: • 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.

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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.

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Aging network are viable subcontractors to

MLTC plans

Services must be appropriately valued both by the plan and the provider

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If you have any specific questions about MLTC, please send an e-mail to mltcworkgroup@health.state.ny.us

Additional information on MLTC is available on the Department’s website at: http://www.health.ny.gov/health_care/medicaid/red

esign/supplemental_info_mrt_proposals.htm

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Send to me 5 regulatory or policy changes to make implementation of all of these reforms easier.

Stay engaged and active.

Work with your Association to provide quality feedback.

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Mark Kissinger’s contact information: ◦ mlk15@health.state.ny.us ◦ 518-402-5673

Stay informed and empowered

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