Department of Health

Providing Integrated Care for New York’s Dual Eligible Members Stakeholder Session

August 2019

Department of Health

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Overview ❑ Current Landscape of New York’s Dual Population

❑ Benefits of Aligning Care for Duals

❑ Alignment Opportunities

❑ FIDA Updates

Department of Health

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Overview of New York’s Duals Programs New York’s Duals Programs

Medicaid Advantage

(MA)

Medicaid Advantage Plus

(MAP)

Programs for All Inclusive Care

for the Elderly (PACE) Partial Managed Long Term

Care

(MLTC) Integrated Plans

Authority 1115 Waiver 1115 Waiver Section 1934 Social Security Act 1115 Waiver

Age 18+ Voluntary 18+ Voluntary 55+ Voluntary

Voluntary, non-dual 18+

Voluntary, dual 18-20

Mandatory, dual 21+

# Enrollees 06/2019 5,175 15,977 5,776 235,945

(90% Dual, 212k)

Enrollment Criteria

Medicare Parts A&B, or enrolled

in Medicare Part C; Enrolled in

plan’s Medicare Advantage

Product

>120 days of LTSS, NH LOC

Medicare Part A&B, or enrolled in

Part C; Enrolled in plan’s

Medicare Advantage Plus

Product

>120 days LTSS, NH LOC

May be any or all of the following:

Medicare Part A; enrolled under Part B;

or eligible for Medicaid

Voluntary; >120 days LTSS, NH LOC

Mandatory; >120 days LTSS

LTSS Provided by Medicaid FFS Yes Yes Yes

# of Plans 3 7 9 27

There are also over 500,000 Full-Benefit Duals in Medicaid Fee For Service

Department of Health

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Where Are NY’s Duals Today? Opportunities for Continuity of Care

Low

Integration

Full

Integration

Data as of June 2018 Medicare

Placement Medicaid MCO Medicaid FFS % of Total

Medicare DSNP

with Medicaid

Contract Aligned*

22,623 0 3%

Medicare DSNP

with Medicaid

Contract Not

Aligned*

59,727 142,347 27%

Medicare

Advantage

Excluding DSNPs

42,755 68,115 15%

Medicare FFS 118,096 300,156 55%

Totals 243,201 510,618 100%

• Overall, only 3% of

membership is aligned

• There is a significant

population in

unaligned DSNPS that

present an opportunity

*Aligned is defined as being in the same plan for Medicaid and Medicare

Department of Health

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Why Align? • Simplification for Members to Improve Member Outcomes

• Aligned Clinical and Financial Incentives between Medicare and Medicaid

• Access to Stronger Care Coordination Model

Features of an Integrated Product ✓Continuity of care ✓Increased provider engagement

✓Person-centered care coordination ✓Ability to offer consumer incentives under Medicare

✓Integrated member services, member materials and ✓Coordinated communication with CMS

review process ✓Frailty adjuster

✓Unified process and review of marketing materials ✓Integrated data to better inform analytics, risk adjustment,

✓Coordinated appeals and grievances and rate setting

✓Aligned enrollment/disenrollment ✓Benefit package alignment

Department of Health

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Alignment Opportunities

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fi~:'K Department ~ATE of Health

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What Happens Today as a Medicaid Member Becomes Dual by Turning 65?

Mainstream

Managed

Care Member

Medicaid

Medicaid

Medicare

Medicare

Choose MAP, PACE, MLTC

Partial, if no choice made,

enrolled to affiliated MLTC

Partial or other MLTC Partial

Medicare FFS or Advantage

Enrolled in FFS unless Member

chooses Medicaid Advantage

Medicare FFS or Advantage

Department of Health

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How Can We Better Align Duals?

The State can use CMS enrollment procedures for members as they

become dual eligible to align them into a MAP or MA plan

• Members would have the ability to opt out

• Members would still be able to select the plan of their choice

(PACE, MAP, MA, or MLTCP)

• Non LTSS Members will still have the choice to opt to FFS

Department of Health

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Member Timeline for Enrollment

Mainstream Enrollment

June 1st June 15th June 30th

Medicare Enrollment

Sept 30th

Members Move to MA/MAP Start

April May June July OctAug-Sept

This timeline reflects the overall movement for a member as they become dual eligible; the

State is working to operationalize this process

Step 3

Step 2

Step 0

Step 1

Step 5

Step 4

fi~:'K Department ~ATE of Health

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CMS Enrollment Procedure Process Step 5

Unless member opts out, member

enrolls into aligned product

Step 3 NYS shares

Step 0 Plan seeks approval

from CMS to begin

enrollment

procedure

Medicare eligibles

list with plans

90 Days Prior:

NYS notifies plan that

member will become

eligible in 90 days

Member becomes

Medicare eligible

Step 2 NYS identifies target

default population

(those most likely to

become dual: 87%

FPL)

120 Days Prior (or

earlier):

NYS works with CMS to

determine prospective

Medicare members

Step 1 NYS receives Medicare

eligible listing from CMS

60 Days Prior:

Plan notifies member that they

will be Medicare eligible in 60

days and enrolled in the

aligned product

Step 4 Plan to send member

notice

The State is working to operationalize this process

Department of Health

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Step 0: Plans Seek CMS Approval to Begin CMS Enrollment Procedure

Plan Application Support

• •

CMS provides support to States and Plans, including offering a Sample Model Notice (see next slide)

NYS is providing support to Plans in establishing the required data procedures and appropriately identifying the eligible

population

Subject to CMS approval, select Medicare Advantage organizations may automatically enroll newly certain

eligible Medicare beneficiaries into a dual eligible Medicare Advantage special needs plan (D-SNP) with member

ability to opt out

Individual Requirements

• Newly eligible for Medicare Advantage

• Currently enrolled in corresponding MMC (or under parent org)

• Will remain in Medicaid Managed Care upon Medicare enrollment

Plan Requirements

• Must have affiliated Medicaid Managed Care Products with DSNP

• Must demonstrate State approval and State agreement to provide necessary information for the Medicare Advantage plan to identify members in their Medicaid Managed Care who are in their Medicare Advantage initial coverage election period

• Minimum Medicare 3 star quality rating

• Obtain CMS approval through a proposal

• Must meet specific notice and timeline requirements

Note , n..,-.,. ma -.,i.te of-ltttertolN!.- inthio pr<><H'-AII IMten .....i will <<>nUin

-require<l (MSdis<lo-., ....,teriaols lO,--r~ te CMSw__,app,aval priar to uoe.

<Ciy>, <Stale> <ZIP>

IMPORTANT: Your health and drug plan is changing.

Dear <Name ol MemDef>

Wea1ewritind 1oll!t you kn-aboutimportan1cha~s !oyourmedical andprescriptioodrug cove1aoe. As your Medicaid plan, we'd like to thank you lor your membefship in <Medicaid MCO Plan Name>, offered by <Parenl Oroanization Name>.

Because youwilbeeligiblellxMedicaresoon. <ParenlOryaniziltionName> wil automatica lly enroll you Into <D-SNP Name> !or you r Medicare benefits. This coverage will 11a n on <inu n tl!Ktive date a Pan A and B ellectiYe date>, the aame day your Medicare benefits ··~ You currently have <state~cific name for Meticaid progr,m> (Medicaid). <D-SNP name>, olle,ed by <paren10<9ani.:atiooname>. help,iyou1Medt::areand<Medicaidorstate-specific Medicaid name> benefit• wort. togethe,

If you don"! want <D-SNP name> lo provid<! your Medicare coverage. you can choose le yet yourMedicarecoverage !hroughanothefplanorlhrouyhOfiginalMedieare. ll youdon' lmake anothercholc<! by <in1endatebeloree~ c11'1e data>, you 'llbeenrolledwith <D-SNP name> 1tarting <in1enetrectlvedate>.

Your <1tate-1J)e(: ific name lor Medicaid p rog111m> cove111oe won'! change [lnsen M applicatle: <due to enrollment in <O-SNP name>, Original Medica•e or another Medicare health plan> You wil conlinoe lcget your <state..specificnameforMedicaidprogr1m> coveraoe through <Medic.aid MCO Plan Name>

You don '! Mve to do anything unlen yoo don't want to be au1omalically enroled in <O-SNP name>. llyoudon'tmakeanolherchoiceby<insert daybeforeeffecliYedate>, your new cove,*wilstarton cinsertellectrvedate>.

f or more information about yoor <D-SNP name> and the beriefits and seMCes you, new plan cove-s, or to lindoutil you can11iHsee your curren1 provider1in your newplan 1nd whetl>er your new plan coven an olyour pre1cription drug, , n l <O-SNP name> at <phorle oombe!>. TTY use,s should cal -<TTY number>-. We are open <dayslllours ol operation and, ~ different, TTY hoursoloperalion>

Medicare Managed Care Manual

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Department of Health

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Step 0: Plans Seek CMS Approval to Begin CMS Enrollment Procedure

Model Notice Medicare Manual Update

https://www.cms.gov/Medicare/Eligibility-and-https://www.integratedcareresourcecen

Enrollment/MedicareMangCareEligEnrol/Downloads/CY_201 ter.com/resource/default-enrollment-9_MA_Enrollment_and_Disenrollment_Guidance.pdf model-notice (Default Enrollment starts at section 40.1.4)

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Department of Health

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Next Steps For CMS Enrollment Procedures

• State establishes CMS Enrollment Procedure Design

• Plans begin process with CMS for Enrollment approval

• System changes occur to implement design

• Plans not currently eligible for CMS Enrollment Procedures to work with NYS and CMS on product line approval for November deadline

2019

• CMS approval of State Design and Plan application

• Plans not currently eligible for CMS Enrollment Procedures continue to work with NYS and CMS on plan approvals

• CMS Enrollment Procedure begins 2020

High Level Medicare Timeline

Intent to Apply

for Medicare

2021

Nov ‘19

Apply for Submit

Medicare 2021 Medicare Bid

Feb ‘20 Jun ‘20

Begin

New Medicare

MA/MAP Offering

Jan ‘21

®;.....__ ___________ _

Department of Health

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Path Forward For Integrated Members

Goals: Improve member outcome & experience through:

Strategies

Member choice and

continuity of care Member alignment and

integrated products

Partnering with plans,

providers, and

stakeholders to improve

outcomes

Item Enhance MAP through

integrated G&A

Medicare CMS Enrollment Procedure for MMC into Medicaid Advantage or

MAP

Enhance MAP and Medicaid Advantage

through integrated BH, including HARP benefits

Medicaid Advantage Choice/Opt-out for Non-

LTSS duals in Medicaid FFS today

Department of Health

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Program Updates

~i:K Department ----- STATE of Health

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2019 FIDA Wind Down Timeline

October 2:

Members that have not

chosen to transition to

MAP will receive a

letter outlining their

enrollment choices

Late March (could be

earlier): Consistent with

CMS guidance, FIDA

plans may begin

marketing affiliated

CY2019 MAP to FIDA

enrollees

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December 31:

End of FIDA

December 20:

Any FIDA member that does not make a choice/is not

passively enrolled by this date will be auto-assigned to

the FIDA plan’s affiliated MLTC Partial Plan, Medicare

fee-for-service and a zero cost-share Part D plan

In July, there were 2,705 FIDA enrollees as compared

to 3,135 in January

2020

July: CMS releases the county-level

DOH released a

FIDA Phase-out

results of the three pronged test;

Plan for a 30 day

comment period

Mid August:

counties that did not pass

plans may focus marketing efforts on

DOH submits revised Phase-out

Plan to CMS

May 20: October: April:

CMS and DOH will send a Per the current FIDA Individuals in counties that

letter to FIDA plans in April MOU/three-way contract, pass the three pronged test

outlining the crosswalk individuals can no longer can begin to be passively

requirements and info FIDA opt into FIDA plan with an enrolled/cross walked into

plans will need to submit effective date 7/1/19 or affiliated MAP for 1/1/2020

later

Department of Health

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Future Discussions / Next Steps • Continued discussion with CMS on enrollment procedures

• Closing out FIDA Program

• We continue to welcome stakeholder feedback at dualintegration@health.ny.gov

Department of Health

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Appendix

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w RK D ATE fepartment - 0 Health

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What Would Utilizing CMS Enrollment Procedures Look Like?

Mainstream

Managed

Care Member

Members have the ability to opt out of this enrollment

and retain full choice options

Medicaid

Through Enrollment Procedures,

Mainstream member would enroll

in the Medicaid Advantage Plus

product of their affiliated

Mainstream Plan

Medicare Enrolled in affiliated DSNP

Medicaid

Through Enrollment Procedures,

Mainstream member would enroll

in the Medicaid Advantage

product of the affiliated

Mainstream Plan

Medicare Enrolled in affiliated DSNP