MLTC and FIDAMay 16, 2014
Managed LTC Expands to Nursing Homes:Are You Ready?
Presented by:
Veronica M. Bencivenga, CPADirectorHMM Consulting.Office: (631) 265-6289E-Mail: [email protected]
New York State Health Facilities AssociationAudio Conference Series
2
Today’s Agenda… Introduction
Care Management for All
Managed Long Term Care (MLTC)
Nursing Home Transition to Managed Care
Impact on SNF Operations
FIDA Update
Funding Opportunities - DSRIP, NHQP, VAP
Managed Care Contracting
3
Introduction
The Problem
Soaring Cost of Healthcare• The US spends 16% of it’s GDP on healthcare –
nearly double all other countries– Schoolhouse Rock! Tyrannosaurus Debt
• New York spent nearly double the national average per recipient
• Not reflected in quality – ranked 50th in hospitalizations
• Unless spending is contained, the New York Medicaid Program will no longer be sustainable
www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf
4
5
•Fee for Service Credit Card–Medicaid and traditional Medicare–Patient uses any provider–Care not coordinated, duplicative services
•Managed Care Gift Card–Costs are predictable–Services and specialists are coordinated
based on comprehensive plan of care
The Problem
The Solution
• Medicaid Redesign• Care Management for All• Managed Care with Capitated Reimbursement
• New Funding Opportunities to promote innovative programs, reduced hospitalizations, and quality care at lower costs – DSRIP, NHQP, VAP
• Providers of all types need to “collaborate” and strategically plan for their survival.
6
7
Care Management For All
Care Management For All
Source: http://www.health.ny.gov/health_care/medicaid/redesign/docs/care_manage_for_all.pdf
Care Management for All Goals:• Transition virtually all Medicaid patient populations to
care management by April 2016• 5 year plan started SFY 2011/2012 by NYS DOH • Improve benefit coordination, quality of care, and
patient outcomes (better care, better health, lower costs)
• Redirect Medicaid spending from fee-for-service to capitation
• Ability to expand coverage and eligibility to more New Yorkers
8
Care Management For All
9
Care Management For All1980’s
Managed CareA collaborative process of assessment, planning, facilitation and advocacy for options and services to meet a consumer’s health needs through communication and available resources to promote high quality, cost-effective outcomes.
VS
Any arrangement for health care in which an organization has administrative control over primary health care services to eliminate redundant facilities and services and to reduce costs. Health education and preventive medicine are emphasized.
2011
Care Management
10
Care Management For All
Drink the
Kool-aid!
11
12
MLTCManaged Long Term Care
Types of Managed Care
13•SOURCE: http://www.nyaprs.org/conferences/executive-seminars/executive-seminar-2012/documents/ValerieBogartMLTCchanges2012forMRC.pdf
Coming soon…
FIDA
14
Types of Managed Care Plans• Managed Long-Term Care – 3 types
• Partially Capitated MLTC (MLTC-P)• Program of All-Inclusive Care for the Elderly (PACE) –
services provided at ADHC• Medicaid Advantage Plus (MAP)
• Mainstream Medicaid Managed Care (MMC)• Other Managed Care (don’t cover LTC)
• Medicare Advantage • Medicaid Advantage
• Future Programs• FIDA (Medicare and Medicaid) for dual eligible
15
Managed Medicaid Plans
• Do you qualify for Medicaid?• What level/type of health care service do you need?
– Routine (CHP, FHP)
– Long Term Care (Community based LTSS, Nursing Home)
– OPWDD/OMH
• Are you eligible for Medicare (Dual Eligible)?• Are you in a FIDA County (NYC, Nassau, Suffolk, Westchester)?
MMCMedicaid Managed Care
(aka Mainstream)
MLTCManaged Long
Term Care or
16
Medicaid Long Term CareMedicaid long term care populations being enrolled into Managed Care
TO BE COMPLETED
• Nursing Home• NHTD• TBI• ALP• Hospice• OPWDD• OMH • OASAS
TRANSITION COMPLETE
• PC• LTHHCP• CHHA• ADHC• AIDS ADHC• PDN• CDPAS
17
Summary of Covered Services
•Source: “Managing Long Term Care Services for Dual Eligibles”, Patrick J Roohan, New York State Department of Health, September 27, 2010
MLTC-P MAP PACECare management X X XHome nursing X X XHome health aides X X XPersonal care X X XNutrition services X X XAdult day health care X X XMedical social services X X XNon-emergency transportation X X XDurable medical equipment X X XPersonal emergency response system X X XPhysical, occupational, respiratory, and speech therapy X X XNursing home care X X XPhysician care X XInpatient hospital care X XOutpatient hospital care X XLaboratory/Radiology services X XDialysis X XMental health, substance abuse, and OPWDD services X XPrescription drugs X XEmergency transportation X X
MLTC-P PACE MAP
Insurance Medicaid ONLY Medicaid AND Medicare
Age 18 + 55 + 18 +
Services Managed
Partially Capitated Fully CapitatedLong Term Care ONLY
ANDDental, Podiatry, Audiology, DME
All MedicalAND
Long Term CareNEW YORK CITY
# of Plans * 25 2 11# of Enrollees * 111,231 3,432 4,605
REST OF THE STATE# of Plans * 12 6 5# of Enrollees * 3,152 2,012 325
18
Comparison MLTC
*Information as of January 2014Source: http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
19
MLTC Plans - Alpha
Source: http://www.health.ny.gov/health_care/managed_care/mltc/mltcplans.htm
20
MLTC Plans – By County
Source: http://www.health.ny.gov/health_care/managed_care/mltc/consumer_guides/nyc/availability/mltc_plans_nyc.htm
Mandatory required to enroll in MLTC:• Dual eligible• Age 21 and over• Require 120+ Days of Community Based Long
Term Care Services (i.e. Personal Care, Nursing, ADHC, Therapy)
• Require permanent placement in a nursing home for custodial care on or after 6/1/2014
• Based on DOH Phase-In Schedule
21
MLTC Enrollment
Exempt can enroll but not required:• Native Americans• Adults age 18-20 who require 120+ days of
Community Based Long Term Care Services• Adults who are nursing home eligible and enrolled
in Medicaid Program for the working disabled
22
MLTC Enrollment
Excluded not eligible to enroll:• Nursing Home Transition and Diversion (NHTD) waiver • TBI waiver• ALP• Hospice• Residents of a psychiatric care facility• Individuals receiving residential and/or community-
based services through OPWDD, OMH and OASAS• Existing nursing home residents established prior
to 6/1/2014 are excluded for a time, then become EXEMPT based on DOH Phase-In Schedule
23
MLTC Enrollment
24
Nursing Home Transitionto
Managed Care
25
Environment today• Payment Reform
– Medicaid Managed CareFIDA – for Duals
– Quality Pools– OMIG Audits (NAMI, Bedhold, etc.)
• Patient Centered Care Coordination– Managing “transitions in care” to increase quality
and save money – no more Patient “hot potato”• Technological Enhancements
– Increase EMR adoption and utilization– Performance monitoring – 5 Star rating, NHQP, census
reporting, hospital readmissions, patient satisfaction, etc.
26
SNF Transition Issues• Protect cashflow – Soft census, billing changes• Contracts – Getting them, terms• Partnering with plans and hospitals • Understand SNF vs. Plan role in managing
“transitions in care”• Educate staff
• Admissions, Social Work, Case Management, Billing• Educate Families
• NY Medicaid Choice (http://www.nymedicaidchoice.com/)
27
Nursing Home Transition
Source: http://nyshfapriority.nyshfa.org/attachment/245/mm14-143.pdf?g_download=1
Source: http://www.health.ny.gov/health_care/medicaid/redesign/docs/2014-03-10_trns_of_nh_services.pdf
28
Nursing Home Transition
General• Effective June 1, 2014 • Current recipients in custodial care will not be
required to enroll, but can on a voluntary basis. • No one will be required to change nursing homes. • Dual Eligible and Non-Dual Eligible over 21 will be
required to enroll in a MLTC or MMC (Medicaid Managed Care Plan).
• Non-dual eligible needing NH long term placement after June 1, 2014 will no longer be dis-enrolled.
29
Phase-In Schedule
30
New Long Term PlacementLTC placement determination consistent with current practice and regulation
• Recommendation made by physician• Based on medical necessity, functional criteria and
availability of services in community (HCBS)• Based on goals, needs and desires of the
individual – Patient Centered Care Plan• Parties involved in determination:
• Nursing home, Plan (if enrolled), hospital discharge planner, LDSS, consumer/family/designee
• Goal is to assure individual receives care in most integrated, least restrictive setting
31
Eligibility
General• NH or hospital must assist the member in applying for
long term eligibility with LDSS• Nursing Home transmits LDSS-3559 and Plan authorization if
patient already enrolled in managed care
• LDSS continues to determine financial eligibility based on chronic care budgeting rules
• 60 month lookback, annual re-certification
• LDSS notifies NH (and Plan) of the NAMI amount• LDSS not involved in plan selection
• Enrollment Broker – New York Medicaid Choice (aka MAXIMUS)
32
Eligibility
General (continued)• NAMI - Plan responsible for collecting NAMI from the
member unless Plan contracts with NH to collect• Contract must specify how PA money to be handled if Plan
collects NAMI• State seeking approval from CMS to contract with a third party
vendor to collect NAMI on behalf of the Plan and NH.
• Rosters – SNFs will continue to receive their FFS rosters via current delivery method
• Will include rate and exception codes
33
Eligibility
Restriction/Exemption Codes.• If approved, LDSS will enter specific
Restriction/Exception (R/E) codes into WMS to identify the type of long term placement for managed care enrollees.
• These R/E codes will appear on plan rosters.• ePACES will also reflect this information.• R/E codes will also drive a Plan’s premium rate
payment.
34
Eligibility
Restriction/Exemption Codes.
• Mainstream R/E codes:o N1 Regular SNF Rate – MC Enrolleeo N2 SNF AIDS – MC Enrolleeo N3 SNF Neuro-Behavioral - MC Enrolleeo N4 SNF TBI - MC Enrolleeo N5 SNF Ventilator Dependent - MC Enrolleeo N6 NH Penalty (consumer is ineligible for NH
services for determined period)• MLTC R/E code:
o N7 MLTC enrollee placed in SNF
Eligibility
35
36
Eligibility
Pending – Not in a plan• The State will not pay for the pending period prior
to determination – NO CHANGE • If eligibility approved, State will pay the NH
minus the NAMI amount until they are enrolled in a plan, then the Plan will pay.
• If ineligible, the patient will be private and the NH responsible for collecting from the patient. - NO CHANGE
37
Eligibility
Pending – Enrolled in a plan• The plan will pay the NH while the chronic care re-
budgeting is pending.• If eligibility approved, the plan will collect any
applicable NAMI amounts from the member.• If not approved, the plan can recoup funds from the
NH for the period eligibility was pending and coordinate a safe discharge to the community with supports
• Patient would be private pay and the NH would collect directly from the member
38
Network Requirements
• If plans do not have a nursing home to meet the needs of its members, it must authorize out of network.
• Members will be allowed to change plans to access the desired nursing homes (no lock –in).
• Direct patients to plans you have a relationship with
• If beds are not available at the time of placement, the plan must authorize out of network.
• Member must have choice of two participating NH’s with available beds
39
Discharge Planning
• Plan must work with NH to ensure members are receiving care in the least restrictive setting. The decision should not be based on finance
• Plan should be notified of all discharges• The NH, Plan, and member or representative must
all be involved in discharge planning.• The NH is responsible for creating and executing
the care plan while in the facility.• Plan may authorize and review care plans.• Plan must authorize all community supports
needed to retain the member in the community, if appropriate
40
Reimbursement
During Transition• Benchmark rate guaranteed for 3 years
• Includes all aspects of NH FFS rate, including but not limited to Operating, Capital, Per Diems, Cash Assessment, Case Mix and Quality
• Will include Universal Settlement if it passes
• Can negotiate a rate acceptable to all parties and approved by DOH (risk sharing arrangement)
• Contracted rate must be increased by the Plan if it falls below the current market Benchmark rate at any time
41
Reimbursement
During Transition (continued)• Bedhold
• Policy remains the same, although prior authorization may be required
• Pharmacy• Current NH pharmacy arrangements must be
honored during 3 year transition period unless another arrangement is negotiated
42
Capital
• Calculated by DOH• Passed through from Plans to Providers• “Guaranteed” after 3 year transition• NH Capital Workgroup will identify changes
needed• Capital Pool
43
Care Transition Challenges• Disagreement on care plan/placement
• Enrollee contests decision or specific placement• Provider recommendation denied by MCO• MCO appeal, external appeal and fair hearing rights• Enrollee may change plans• ALC coverage in place until safe discharge
• No available community service/bed• Coverage in place until safe discharge• Out of network options
• Dispute over process/roles/billing• DOH complaint process
MLTC: 1-866-712-7197MMCP: 1-800-206-8125
44
Impact on Providers
Innovation
or
Devastation
YOU decide!
Contract Negotiation
Admission and Discharge practices
Case Management – skilled staff required!
Revenue Cycle Management
Internal Communications
AgendaImpact on Providers
45
Contract NegotiationContract Negotiation • Will be evolutionary and vary greatly by Plan• Know your strengths and be able to demonstrate
(QUANITFY) them:• 5 Star rating (what it is and why, back story)• NHQP Score• Average LOS• Hospital readmission statistics• Staffing (NP or PA, Wound care nurse, etc.) • Special services (i.e., Diabetes management
training for patient and family, bariatric, memory impaired)
46
47
Impact on ProvidersSample Master Insurance Schedule
ABC Nursing and Rehab FacilityRevised: 11/27/13
Manage Care Plans: Products: Level 1 Level 2 Level 3 Level 4 Level 5 NotesRevenue Codes 190, 191, 199 192 193 194 195HIP & Magnacare 121, 128, 110 148 158 138
ALL INSURANCE PLANS Out of Network‐All‐Mcr/Mcd/HMO/PPO etc $325 $425 $525 $625 $725 Or at Medicare Rate ‐ MDS Rate
Aetna All‐MCR/MCD/HMO/PPO/EPO etc $240 $240 $340 $340 N/A Rate increase requested…..Currently being reviewed
Affinity Health Plan Medicaid $255 $330 $360 $650 N/A Rate increase received…Effective date 04/01/2013
Affinity Health Plan Medicare Rate increase received…Effective date 04/01/2013
Amerigroup/Healthplus Medicare 400 400 400 400 N/A One Flat Rate……Effective date 11/12/2012
Amerigroup/Healthplus Medicaid 250 $250 $250 $250 N/A One Flat Rate……Effective date 11/12/2012
Cigna All‐MCR/MCD/HMO/PPO/EPO etc $375 $475 $575 $650 N/A
EasyChoice/Atlantis Medicare/Medicaid Not Contracted ‐ Contract Request sent…Should be receiving contract in a month
Elderplan Medicare/Medicaid $330 $430 $530 $600 New contract….Effective date 03/05/2013
Elderplan MLTC Program New contract….Effective date 03/05/2013
Empire BC/BS/Wellpoint All‐MCR/MCD/HMO/PPO/EPO etc 300 475 575 575 N/A New Rates…Effective date 12/01/2012
Fidelis Care of NY Medicare/Medicaid 225 $275 $325 $400 N/A New contract….Effective date 03/21/2013
GHI Commercial/HMO/PPO/EPO/POS 325 425 550 N/A N/ANo Level 4, reserve for Vent patients..New Rates effective date 10/01/2012
GHI Medicare/No Medicaid Program 310 $375 425 N/A N/ANo Level 4, reserve for Vent patients..New Rates effective date 10/01/2012
Guildnet Medicaid Not Contracted. Will be receiving paper work soon.
Healthcare Partners MedicareNot Contracted. Will be submitting paper work for their review.
HealthNet Medicare $240 + qpd $315 + qpd $400 + qpd $510 + qpd Quality Product Distribution
Levels of Care
100% Medicare RUGS score
100% Medicaid Rate
Admission and DischargeAdmissions Practices • Benefit verification (on-line and by phone)• Authorizations (level, timeframe)• Family education (benefits counseling)
Discharge Practices• Change perception of who is dischargeable• Discharge begins on admission• Work with Plan on target discharge date
• Not under your control anymore• Discharge planning more involved
• Coordinating with multiple Plans to identify approved providers
48
Benefit Verification
49
Case Management• Dedicated resources• Experienced• Proactive• Excellent communication skills (documentation
comes from your EMR)• Work with Business Office and Administration to
identify and resolve payment issues timely
50
Billing Frequency
• Bill on day of, or day after, discharge
• Weekly billing ALL payers excluding Medicare A
Billing Tools
• Claims Management Software
• Clearing house (Emdeon, Capario, RelayHealth)
• Outsource billing
Collections• Will spend more time
to collect same or less money for short term patients
Revenue Cycle Management
Cashflow
Clean claimsare critical
51
Communication• Staff
• Interdisiplinary• Real-time (EMR, e-mail, secure texting)
• Families• Educate about plans, benefits (or lack of), and
who is paying when• Difference between your decisions and the
insurers (discharge date, services authorized)• Vendors
• Patient’s primary payers/plans, who to bill
52
53
FIDAFully Integrated Duals Advantage Program
54
FIDA Demonstration Update
• A key step in the move to “care management for all”• 8/26/13 CMS approved NY participation FIDA
demonstration project
• Demonstration runs from July 2014 – December 2017• FIDA Demonstration Counties - NYC, Westchester,
Nassau, Suffolk only
Fully Integrated Dual Advantage (FIDA)
Source: http://www.health.ny.gov/health_care/medicaid/redesign/docs/2014-01-10_fida_stakeholders.pdf
FIDA Demonstration UpdateHighlights:• All plans will be MLTC’s that modify offerings to
include Medicare services.• No change in service level for first 90 days• Dual eligible residents in nursing homes are eligible for
the demonstration• Conversion-in-place • Beneficiaries can “opt out” of the demonstration at any
time• New Duals will be enrolled in FIDA• If opt out, must join an MLTC and FFS Medicare
plan (FFS Medicaid not an option)55
56
FIDA Demonstration UpdateProposed Covered Benefits: • Use the NY Medicaid definition of medical necessity
for all services. • Covered Services include services covered by the
existing Medicare and Medicaid programs in New York in addition to Home and Community-Based waiver services.
• FIDA plans will have discretion to supplement covered services with non-covered services or items where so doing would address a Participant’s needs, as specified in the Participant’s Person-Centered Service Plan.
57
FIDA Demonstration UpdateTwo Types of Plans:
Primary FIDA – Dual eligibles, age 21 and over that require community-based long term care services for more than 120 days who are not residents of an OMH facility, and who are not receiving services from the OPWDD system.
•Geographic Service Area: Bronx, Kings, New York, Queens, Richmond, Nassau, Suffolk and Westchester Counties
OPWDD FIDA – Dual eligibles, age 21 and over, who are not residents of an OMH facility, and who are receiving services from the OPWDD system
•�Geographic Service Area: Statewide
58
Duals receiving community-based long-term services and supports (LTSS)
• July 1, 2014 - Voluntary enrollment (opt in)• September 1, 2014 – Passive enrollment of
eligible beneficiaries who have not made a choice to opt in or out
Duals in Nursing Homes:• October 1, 2014 - Voluntary enrollment (opt in)• January 1, 2015 - Passive enrollment of
eligible beneficiaries who have not made a choice to opt in or out
FIDA Demonstration UpdateFIDA Timeline:
59
Continuity of Care:• Participants have access to all providers, all authorized
services, and preexisting service plans including prescription drugs for 90 days or until the Person Centered Service Plan is finalized and implemented, which is later. Participants can maintain their existing Nursing Home provider for the duration of the demonstration.
• All FIDA Plans must have contracts or payment arrangements with all nursing homes such that nursing home residents who are passively enrolled are afforded access to that nursing home for the duration of the demonstration.
FIDA Demonstration Update
60
Rate Development• Underway
FIDA Demonstration Update
61
SNF Provider concerns:• Contracting
• Getting shut out• Rate setting
• Medicare margin has offset Medicaid losses for years
FIDA Demonstration Update
62
Long Term Care Funding
Opportunities
63
Delivery System Reform Incentive Payments:• NY’s Safety Net relies too heavily on Hospital,
ER and NH use• 25 Programs that target array of providers
including NHs• Goal – Decrease avoidable hospitalization and
ER use by 25% over next 5 years• Over $7 billion will be reinvested • Approved on 4/14/2014 and Funded through a
federal waiver program and Medicaid savings
DSRIP
64
DSRIP Proposals:• DOH wants previously “siloed” providers
to collaborate on proposals• Health Homes should be included• New and unique initiatives• Address significant issues• Achieve substantial, transformative
change
DSRIP
65
Purpose:• $50 Million Pool established as part of the
2010-2011 State Budget as means to reward high-quality care compared to peers
• DOH working with industry to design quality scoring system using existing data sources
• Recognizes and rewards improvements over time
• Redistributes funds from poor performers to high quality performers
Nursing Home Quality Pool (NHQP)
66
Facility Scoring:Three major components:
•14 Quality Measures ( 60 points)
•Three Compliance Measures (20 points)
•One Efficiency Measure - Potentially Avoidable
Hospitalizations (20 points)
Nursing Home Quality Pool (NHQP)
67
Overview:• Goal of the program is to reconfigure operations of
financially fragile providers.• Expected Outcomes are higher quality care at lower
costs.• Providers must submit applications documenting
financial condition, services provided to community, and quality care enhancements to be implemented.
• Capital Costs are not eligible.
Vital Access Providers (VAP)
Questions?
Thank you.
68
69
Resources:• OHIP Transition Document March 2014 - UPDATED:
http://nyshfapriority.nyshfa.org/attachment/245/mm14-143.pdf?g_download=1/
• MLTC Plan Directory: http://www.health.ny.gov/health_care/managed_care/mltc/mltcplans.htm
• MLTC Regional Consumer Guide: http://www.health.ny.gov/health_care/managed_care/mltc/consumer_guides/
• Managed Care Enrollment Reports:https://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/
• Managed Care Program Comaprisonhttps://www.health.ny.gov/professionals/patients/discharge_planning/docs/managed_care_program_comparison.pdf
HMM Consulting a Division of Horan, Martello, Morrone P.C.