Managed Long Term Care & Social Adult Day Care Presentation to the New York State Adult Day Services Association September 30, 2016 Mark Ustin Manatt Health
Agenda 2 1 Background on Managed Long Term Care 2 Medicaid Redesign Team Reforms Today’s Objectives 3 Impact of Reforms on MLTC Relationship with Social Adult Day Care 4 Latest Issues Being Addressed by MLTC
Coalition of MLTC & PACE Plans 3 • Twenty-two not-for-profit, provider-sponsored MLTC, PACE and MAP plans • Provide coverage for more than 70% of the over 170,000 elderly and disabled individuals enrolled in MLTC, PACE and MAP statewide
Agenda 4 1 Background on Managed Long Term Care Today’s Objectives
What is Managed Care? 5 Managed Care Organization receives capitated payment ($X per person per month), and uses those funds to pay for all medically necessary services within benefit packagefor all enrollees Simple in Theory, Complicated in Practice Assessment and care planning Network development and maintenance Enrollment/disenrollment Service authorizations & utilization review Care management Member services and grievance system Rate development Claims management experience and capacity Potential risk-sharing Marketing experience and capacity
NY’s Managed Care Models for Long Term Care 6 Partially MLTC Medicaid Managed Long Term Care capitated Arranges and pays for only Medicaid-covered services, mostly long term care. Coordinates covered and non-covered services. Programs of All-Inclusive Care Fully PACE integrated for the Elderly Arranges and pays for all Medicaid and Medicare services (primary, acute and long term care). Services centered around adult day care center. Fully MAP Medicaid Advantage Plus integrated Arranges and pays for all Medicaid and Medicare services (primary, acute and long term care). Bridges MLTC model with Medicare Advantage plan.
Who is served by managed long term care? 7 MLTC MAP PACE Must have full Medicaid Must be dual eligible (Medicaid Must be eligible for Medicaid coverage and be eligible for & Medicare) or have Medicaid Medicare Must be age 18 or older Must be age 55 or older Must be capable of remaining in the community without jeopardizing health Must require care management and one or more long term care Must be eligible for nursing services for 120+ days home care
Long Term Care Plans in New York State 8 October 2015 August 2016 MLTC Total Enrollment: 128,288 159,575 Total Enrollment: 5,493 5,524 PACE Total Enrollment: 6,210 6,055 MAP
Agenda 9 2 Medicaid Redesign Team Reforms Today’s Objectives 3
History of Medicaid Managed Care in New York 10 Eligibility streamlining and simplification provisions enacted PHSP authorizing Family Health Plus legislation enacted Child Health Plus created Further population and created benefit (personal care, Mandatory MMC Mandatory MMC enrollment pharmacy) expansions enrollment expanded to begins RFP issued for SSI populations MMC providers NYS legislature sets MMC reimbursement goal of enrolling 50% Legislation reforms implemented Facilitated enrollment of Medicaid by 2000 passed program launched imposing 9% surcharge on Mandatory MMC HMOs with too Legislature Plan reserve expanded to intervened to few Medicaid requirements increased HIV/AIDS individuals enrollees raise plan rates 1985 1990 1995 2000 2005 2010 Authorizing legislation enacted for various specific PACE and DOH Interim Report on Mandatory MLTC enrollment MLTC demonstration projects MLTC recommends begins increasing MLTC General MLTC enrollment authorizing legislation DOH Final Report on enacted MLTC recommends further increasing MLTC enrollment CCM Model established
Mandatory MLTC Implementation Plan 11 Post June 2014: Sept. 2012-Feb. 2013: Phase I MLTC Enrollment Phase VI – Mandatory MLTC transition of • Sept. 2012: All dual eligible cases new to service fitting the mandatory previously excluded dual eligible groups: definition in NYC • Nursing Home Transition and Diversion Waiver • Sept. 2012: Personal care cases in New York county and begin personal participants care in Bronx County. • Traumatic Brain Injury Waiver participants • October 2012: Continue personal care cases in New York and Bronx • Assisted Living Program participants counties and begin Kings County. • November 2012: Continue personal care and add consumer directed personal assistance cases in New York, Bronx, and Kings counties. Initiate June 2014: June 2013: CDPAP Citywide for new enrollees. • Phase V – Mandatory MLTC • Phase III – Mandatory MLTC • December 2012: Continue personal care cases in New York, Bronx and enrollment of dually eligible enrollment of dually eligible Kings counties and begin Queens and Richmond counties. community based long term care community based long term care • January 2013: Initiate enrollments citywide of non-personal care LTC service recipients in “other counties service recipients in Rockland and programs with capacity” Orange counties • February 2013 and until all people in service are enrolled: Citywide MLTC enrollment of all personal care and LTC programs 2012 2013 2014 2014 2012 2013 Jan. 2013: Dec. 2013: • Phase II – Mandatory MLTC transition of • Phase IV – Mandatory MLTC transition dually eligible community based long of dually eligible community based term care service recipients in in Nassau, long term care service recipients in Suffolk and Westchester counties Albany, Erie, Onondaga, and Monroe counties
New Eligibility Standard: Theoretical 12 Department of Health Managed Long Term Care Guide You must join a Plan if: • You have both Medicaid and Medicare • You need home care, adult day health care, or other long term care for more than 120 days (four months) • You are age 21 or older
New Eligibility Standard: Practical 13 Department of Health Website • Am I eligible for managed long-term care? You are eligible to enroll in managed long-term care if you: • have a chronic illness or disability that makes you eligible for services usually provided in a nursing home; • are able to stay safely at home at the time you join the plan; • are expected to need long-term care services for at least 120 days from the date you enroll; • meet the age requirement of the plan (the age requirement for a PACE organization is 55 years old; for most other plans, the age requirement is 65 years old); • live in the area served by the plan; • have or are willing to change to a doctor who is willing to work with the plan; and • have a way of paying that is accepted by the plan. All plans accept Medicaid. Some plans also accept Medicare and private pay.
Implications for SADC 14 • MLTC Policy 13.03 (1/25/13): SADC is a covered benefit, but does NOT count for eligibility (only personal care services in the home ) • MLTC Policy 13.05 (2/28/13): SADC cannot represent an enrollee’s complete plan of care
Agenda 15 Today’s Objectives 3 Impact of Reforms on MLTC Relationship with Social Adult Day Care
Some Bad Press in April 2013 16 Plans accused of questionable arrangements with social adult day care facilities Unregulated facilities Questionable services Potentially improper incentives Dubious eligibility Enrollment was suspended in one large plan, and a series of investigations were initiated
DOH Regulatory Response 17 Medicaid Director Letter 4/26/13 : SADC cannot represent the primary service in a plan of care All plans required to immediately reassess enrollees receiving SADC OMIG audits pending Reminder that plans may not offer “materials, financial gain or service incentives” as an inducement to enroll No marketing permitted at, or referrals permitted from, SADC sites
More New DOH Policy Statements 18 MLTC Policy 13.11 (5/8/13): • If, upon reassessment, an enrollee does not need or refuses CBLTC services (e.g. in-home personal care), should be disenrolled • Fee-for-service Medicaid will not pay for SADC • Plans must formally credential all providers, including SADC programs, at least every three years • All contracted SADC programs must meet SOFA standards
More New DOH Policy Statements 19 MLTC Policy 13.14 (5/30/13): • No required or recommended service mix or ratio of CBLTC to SADC services MLTC Policy 13.15 (6/10/13): • Individuals who only require housekeeping do not meet MLTC eligibility requirement
Credentialing of SADC Programs 20 • DOH circulated list of suspect programs (including some that met SOFA standards and some that did not) • Plans argued that imposing individual responsibility for SADC program credentialing was too burdensome MLTC Policy 15.01 (5/8/15): • Requires new annual certification process for any SADC programs contracting with MLTCPs • MLTCPs must ensure contracted SADC programs have certification • MLTCs still required to conduct annual site inspections of SADC programs
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