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: vbencivenga@horanmm.comwww.horanmm.com

New York State Health Facilities AssociationAudio Conference Series

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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

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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

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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

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.

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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

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Care Management For All

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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

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Care Management For All

Drink the

Kool-aid!

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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

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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

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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

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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

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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

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

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Comparison MLTC

*Information as of January 2014Source: http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/

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MLTC Plans - Alpha

Source: http://www.health.ny.gov/health_care/managed_care/mltc/mltcplans.htm

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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

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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

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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

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MLTC Enrollment

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Nursing Home Transitionto

Managed Care

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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.

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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/)

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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

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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.

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Phase-In Schedule

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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

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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)

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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

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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.

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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

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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

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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

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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

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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

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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

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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

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Capital

• Calculated by DOH• Passed through from Plans to Providers• “Guaranteed” after 3 year transition• NH Capital Workgroup will identify changes

needed• Capital Pool

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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

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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

AgendaImpact on Providers

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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)

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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

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Benefit Verification

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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

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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

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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

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FIDAFully Integrated Duals Advantage Program 

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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 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

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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.

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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

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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 UpdateFIDA Timeline:

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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

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Rate Development• Underway

FIDA Demonstration Update

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SNF Provider concerns:• Contracting

• Getting shut out• Rate setting

• Medicare margin has offset Medicaid losses for years

FIDA Demonstration Update

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Long Term Care Funding 

Opportunities

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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

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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

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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)

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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)

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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.

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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.