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September 18, 2013
Care Management for All: The impact on
Long Term Care Providers
Webcast presented by:
Veronica M. Bencivenga, CPA Director, HMM Consulting
Complimentary Webinar sponsored by:
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Today’s Agenda…
Understanding “Care Management for All” and the progress to date
Impact of managed care transition on long term care providers daily operations
Resources to monitor status of MRT initiatives
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 spends, per recipient, nearly double the nation average
• 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
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•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
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The Solution
2008-2010 : National healthcare debate
2008 : Triple Aim • Originally developed by the Institute for Healthcare
Improvement (IHI) • a framework that describes an approach to
optimizing health system performance • adopted by CMS
2010 : Patient Protection and Affordable Care Act (ACA) signed into law March 23, 2010
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Redesigning Medicaid
http://www.health.ny.gov/health_care/medicaid/redesign/
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Redesigning Medicaid
http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf
• Executive Order #5 created the New York Medicaid Redesign Team (MRT) January 5, 2011
• First report with findings and recommendations due by March 1, 2011 (only 60 days) to save money starting with SFY 2011-2012
• Identified 79 program changes and new initiatives to be deployed in 3 phases over 5 years
• NY adopts CMS’s “Triple Aim” vision for health care system redesign, delivery, and payment reform : better health, better care, lowers costs
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Aim #1 Improving Care
• Care Management for All
• Ensure Universal Access to High Quality Primary Care
• Health Homes • Health Care
Workforce for the 21st Century
• Interoperable EHR for All New Yorkers
• Improving Behavioral Health
Redesigning Medicaid
http://www.health.ny.gov/health_care/medicaid/redesign/docs/mrtfinalreport.pdf
Aim #2 Improving Health
• Eliminating Health Disparities
• Affordable and Supportive Housing
• Redesigning New York’s Medicaid Benefit
Aim #3 Reducing Costs
• Global Medicaid Spending Cap
• Strengthening and Transforming the Health Care Safety Net
• Payment Reform • Medical Malpractice
Reform • Redefining the
State/Local Relationship in Medicaid
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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
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Care Management For All
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Care Management For All 1980’s
Managed Care A 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.
2010
Care Management
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Care Management For All
Drink the
Kool-aid!
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FIDA Demonstration Update
• A key step in the move to “care management for all” • 8/26/13 CMS approved NY participation FIDA
demonstration program
Fully Integrated Dual Advantage (FIDA)
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FIDA Demonstration Update Highlights: • All plans will be Medicaid Managed Long Term
Care plans (MLTC’s) that modify offerings to include Medicare services (Carve-in’s).
• Dual enrollees requiring facility-based long-term services and supports are eligible for the demonstration
• “Conversion in place” enrollment-Medicare benefit will be added to their managed care plan’s portfolio
• Beneficiaries can “opt out” of the demonstration at any time.
• Region 1-NYC, Westchester, Nassau, Suffolk • Affects approximately 120,000
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FIDA Demonstration Update Proposed 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.
Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health
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FIDA Demonstration Update Two 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
Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health
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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 Update FIDA Timeline:
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Medicaid payments = Vital revenue How will the state share MRT savings with providers?
Option #1 - “Global” Shared Savings • State captures shared savings by lowering managed care
payments as costs decline. • State then devises mechanisms to make either direct
payments to providers or to require payments through managed care plans.
• Payments could be linked to both performance measures and to ensuring financial survival for vital access providers.
Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health
FIDA Demonstration Update
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Medicaid payments = Vital revenue How will the state share MRT savings with providers?
Option #2 - Managed Care Shared Savings • Require managed care organizations to develop plans for
shared savings with their provider networks. • The state would approve all plan shared savings agreements
and ensure those agreements are enforced. • Plans would be free to use “back end” shared savings
agreements, sub-capitation and performance bonus payments as vehicles for sharing savings with providers.
• Model will be tested in the FIDA demonstration.
Source: Medicaid Redesign Team Update and Next Steps , FAE Health Care Conference September 9, 2013 Jason A. Helgerson, Medicaid Director NYS Department of Health
FIDA Demonstration Update
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Impact on Providers
Innovation
or
Devastation
YOU decide!
Contract Negotiation
Admission and Discharge practices
Case Management – skilled staff required!
Revenue Cycle Management
Internal Communications
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Agenda Impact on Providers
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Impact on Providers Contract Negotiation • Know your strengths and be able to demonstrate
(QUANITFY) them: • 5 Star rating (what it is and why, back story) • 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)
• Rates – Don’t ask, don’t get • NYS Assessment • Acuity Adjustment/Risk Sharing
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Impact on Providers Sample Master Insurance Schedule
ABC Nursing and Rehab FacilityRevised: 6/27/13
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
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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
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Impact on Providers Admissions 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 insurer on target discharge date
• Not under your control anymore
• Discharge planning more involved • Coordinating with multiple insurers to identify approved
providers
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Impact on Providers Case Management • Dedicated resources • Experienced/Certified
• Nurse - Care Manager Certified (CMC) ,Certified Case Manager (CCM)
• Social Worker - Certified Advanced Social Work Case Manager (C-ASWCM), Certified Social Work Case Manager (C-SWCM)
(http://www.caremanager.org/why-care-management/certification-professional-conduct)
• Proactive • Excellent communication skills (documentation
comes from your EMR) • Work with Business Office and Administration to
identify and resolve payment issues timely
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Impact on Providers Revenue Cycle Management • Cash Flow
• Bill on day of, or day after, discharge • Weekly billing all payers
• Billing practices • Claims Management Software • Clearing house (Emdeon, ePremis, Optum)
• Collections • Will spend more time to collect same or less
money
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Impact on Providers Communication • Staff
• Interdisiplinary • Real-time
• 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 payers, plans, who to bill
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Resources
Medicaid Redesign Team: http://www.health.ny.gov/health_care/medicaid/redesign/mrt_101.htm
CMS approves NY FIDA 8/26/13. See MOU fact sheet at: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-Sheets/2013-Fact-
Sheets-Items/2013-08-26.html WNY Law Center:
http://www.wnylc.com/health/entry/114/#exclusion Managed Long Term Care Plan Directory:
http://www.health.ny.gov/health_care/managed_care/mltc/mltcplans.htm Managed Care Organization Directory:
http://www.health.ny.gov/health_care/managed_care/mcplans.htm
Additional information on the transition to Managed Care for LTC providers in New York can be found at:
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Questions?
?
Thank you.
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Veronica M. Bencivenga, CPA Office (631)265-6289 Cell (631)880-2882 VBencivenga@horanmm.com www.horanmm.com
HMM Consulting a Division of Horan, Martello, Morrone P.C.
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