getting to shared risk - leadingage new york to shared ris… · mltcp medicaid premium the...

Getting to Shared Risk

Leading Age NY Financial Managers Conference

Presented By:

Steven HerbstDirector of Managed Care

Wednesday, September 11, 2013

Agenda

Market Dynamics

MLTC Update

FIDA Overview

MOU Implications MOU Implications

Payment Model Concepts

Case Studies

0-MgdCare/13 Pres/9999i09sh.ppt 1

What’s Going on in the Market Today?

Change in the access, financing and delivery of long term care servicesservices

Mandatory enrollment in MLTCP

Care management for all

FIDA development and implementationp p

End of Medicaid fee-for-service as we know it


Agenda

Market Dynamics

MLTC Update

FIDA Overview



Case Studies


MLTCP Basics

Three MLTCP models in operation Program of All-Inclusive Care for the Elderly (PACE)

Medicaid Advantage Plus (MAP)

Partially capitated MLTCP

Fully Integrated Dual Advantage Effective April 1, 2014

NYC W t h t N S ff lk NYC, Westchester, Nassau, Suffolk


MLTCP Covered Benefits

The Medicaid Managed Long Term Care Plan is

MLTCP Covered Services Include:Term Care Plan is

Designed as an alternative to institutional care

• Care Management• Home Care• Optometry• Dental Services

• Medical Social Services

• Personal Care• Podiatry

Serves frail, long-term care eligible population

Covers Medicaid home care

• Rehabilitation Therapies

• Audiology• Respiratory Therapy

• Non-Emergency Transportation

• Home Delivered MealsDMEand long term care services • Nutrition

• Social and Environmental Supports

• DME• Social Day Care• Prostheses• Adult Day Care

• Nursing Home Care

50-MgdCare/13 Pres/9999i09sh.ppt

MLTCP Eligibility Requirements

At least 18 years old and eligible for Medicaid In need of community-based long-term care for more than 120 days; defined In need of community based long term care for more than 120 days; defined

as: Personal Care Services Certified Home Health Agency Servicesg y Long Term Home Health Care Program Services Adult Day Care Services Private Duty Nursing Services Consumer Directed Personal Assisted Services Social Day Care, used as a substitute for in home Personal Care Services, is not

considered a service for purposes of determining plan eligibility

Able to remain safely at home with assistance (for activities like bathing, dressing, walking or preparing food)


* Currently excluded: NHTD waiver, TBI waiver, NH residents, ALP participant

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MLTCP Medicaid Premium

The 4/1/2011–3/31/2012 Medicaid premium is based on the following:

50% negotiated rate – 50% risk adjusted rate

Regional average costs based on an average of 2008 & 2009 MMCOR data, t d dtrended

Administrative reimbursement capped at $231 pmpm

4/1/2011–3/31/2012 Regional Average Monthly Medicaid Premium

Region 1 - $3,760

R i 2 $2 724 Region 2 - $2,724

Region 3 - $2,406

Region 4 - $1,683


MLTCP Average Expense Data PMPM

Region 1 Region 2‐4 Combined

Category of Service2010 average pmpm expense

2011 average pmpm expense (1)

2010 average pmpm expense

2011 average pmpm expense (1)

Home Health Care 746.47 526.75 215.13 223.30Home Health Care 746.47 526.75 215.13 223.30

Nursing facility 185.88 187.37 352.73 325.51

Transportation 110.01 106.87 151.74 150.99

Personal Care 1,770.37 1,958.50 657.20 753.33

Other Medical 165.09 163.03 370.45 401.62

Care Management 278.04 267.05 252.99 251.44

Administration 324.24 368.68 358.76 337.12

Total 3,580.10 3,578.25 2,359.00 2,443.31

(1) Thru Q3 MMCOR


(1) Thru Q3 MMCOR(2) Based on data provided by DOH

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Proliferation of MLTCPs

August 2012 13 active MLTC plans 13 active MLTC plans 50,000 covered lives

August 2013 23 active MLTC plans 16 pending NYC area MLTC 6 pe d g C a ea C

applications 100,000 covered lives 2 new Medicaid Advantage Plus g

entrants


MLTC Expansion & GrowthMETROPOLITAN NYC AREA MLTC MEMBERSHIP GROWTH ANALYSIS

AUGUST 2013 AUGUST 2012 PLAN NYC METRO SHARE NYC METRO SHARE GROWTH # GROWTH %

AETNA 1,316 1% ‐ 0% 1,316 AGEWELL 1 365 1% 0% 1 365AGEWELL 1,365 1% ‐ 0% 1,365 ALPHACARE 43 0% ‐ 0% 43 AMERIGROUP 2,850 3% 1,516 3% 1,334 88%ARCHCARE 978 1% ‐ 0% 978 CENTERLIGHT 9,076 9% 4,812 10% 4,264 89%CENTERS PLAN 689 1% ‐ 0% 689CENTERS PLAN 689 1% 0% 689 ELDERPLAN 9,983 10% 5,953 12% 4,030 68%ELDERSERVE 9,649 10% 5,889 12% 3,760 64%EXTENDED 10 0% 0% 10 FIDELIS 6,010 6% 140 0% 5,870 4193%GUILDNET 13,348 13% 8,648 17% 4,700 54%HHH CHOICES 2,334 2% 1,425 3% 909 64%EMBLEM 991 1% 83 0% 908 1094%ICS 4,779 5% 2,507 5% 2,272 91%INTEGRA 40 0% 0% 40 METROPLUS 282 0% 0% 282 SENIOR HEALTH PARTNERS 9,788 10% 4,332 9% 5,456 126%SENIOR WHOLE HEALTH 401 0% 0% 401 UNITED 364 0% 0% 364 VILLAGE CARE 2,098 2% 129 0% 1,969 1526%VNSNY CHOICE 18,773 19% 11,991 24% 6,782 57%WELLCARE 4 739 5% 2 804 6% 1 935 69%


WELLCARE 4,739 5% 2,804 6% 1,935 69%TOTAL 99,906 50,229 49,677 99%

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NYC Medicaid & HIV SNP Plans

METROPOLITAN NYC AREA MEDICAID MANAGED CARE MEMBERSHIP GROWTH ANALYSIS AUGUST 2013 AUGUST 2012

PLAN NYC METRO SHARE NYC METRO SHARE GROWTH # GROWTH %PLAN NYC METRO SHARE NYC METRO SHARE GROWTH # GROWTH % Affinity Health Plan 203,343 8% 193,736 8% 9,607 5%Amerigroup 349,851 14% 354,351 14% (4,500) ‐1%HealthFirst PHSP 698,589 27% 659,811 27% 38,778 6%HIP of Greater New York 198,098 8% 200,050 8% (1,952) ‐1%Hudson Health Plan 49 801 2% 45 855 2% 3 946 9%Hudson Health Plan 49,801 2% 45,855 2% 3,946 9%MetroPlus Health Plan 369,356 14% 376,082 15% (6,726) ‐2%NYS Catholic Health Plan 370,938 14% 325,999 13% 44,939 14%United Healthcare Plan of NY 267,965 10% 238,997 10% 28,968 12%Wellcare of New York 58,121 2% 50,714 2% 7,407 15%Grand Total 2 566 062 2 445 595 120 467 5%Grand Total 2,566,062 2,445,595 120,467 5%

METROPOLITAN NYC AREA HIV SNP MEMBERSHIP GROWTH ANALYSIS AUGUST 2013 AUGUST 2012

PLAN NYC METRO SHARE NYC METRO SHARE GROWTH # GROWTH % MetroPlus SN 5,453 33% 5,790 34% (337) ‐6%Amida Care SN 5,904 35% 5,493 32% 411 7%VNSNY CHOICE SN 5,296 32% 5,861 34% (565) ‐10%TOTAL 16,653 17,144 (491) ‐3%


MLTC Mandatory Enrollment Timeline DownstateDownstate

Fall 2012 — Start of mandatory enrollment in NYC - focus on NYC Home Attendant Program recipientsHome Attendant Program recipients

Jan. 2013 — Adult day care and long-stay CHHA members begin to receive mandatory enrollment noticereceive mandatory enrollment notice

Jan. 2013 — Expand mandatory enrollment to Westchester, Nassau & Suffolk

June 2013 — LTHHCP members begin to receive mandatory enrollment notice (members will receive notices over a 3 month period)

July 2014 — FIDA commences


Mainstream Medicaid Managed Care (Medicaid Only)(Medicaid Only)

April 2013 — LTHHCP begins transition to managed care

August 2013 — Adult Day Health Care

— AIDS Adult Day Health Care

Jan. 2014 — Residents of Nursing Facilities (including Medicaid covered hospice benefit and long term NF stay)


MLTC Mandatory Enrollment Timeline UpstateUpstate

As plan capacity is established*, dually eligible community based long term care service recipients will be enrolled asbased long term care service recipients will be enrolled as follows:

Phase III: Rockland and Orange Counties Anticipated Fall 2013 Phase III: Rockland and Orange Counties- Anticipated Fall 2013

Phase IV: Albany, Erie, Onondaga and Monroe Counties- Anticipated December 2013

Phase V: Other counties with capacity- Anticipated June 2014


*Capacity is defined as 2 operational plans per county

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Enrollment Timeline – SNF Residents

Delaying mandatory enrollment of Medicaid-only, permanently placed nursing facility residents into Mainstream Medicaid Managed Care from October 2013 tofacility residents into Mainstream Medicaid Managed Care from October 2013 to January 1, 2014

Allowing permanently placed, dually eligible nursing facility residents, as of December 31, 2013, to remain in fee-for-service

Beginning January 1, 2014 (in FIDA counties), and April 1, 2014 (statewide), requiring all newly designated permanently placed nursing facility residents torequiring all newly designated permanently placed nursing facility residents to enroll in a Managed Long Term Care Plan (dually eligible) or a Mainstream Medicaid Managed Care Plan (Medicaid-only)

Until voluntarily enrollment in a FIDA plan beginning October 2014 or passive enrollment in FIDA beginning January 2015


Agenda

Market Dynamics

MLTC Update

FIDA Overview



Case Studies


What is FIDA?

Fully Integrated Duals Advantage (FIDA) is the State of New York’s participation in the Capitated Financial Alignment Demonstration beingparticipation in the Capitated Financial Alignment Demonstration being administered by CMS’ Medicare-Medicaid Coordination Office

The FIDA demonstration is a three year pilot between NYS DOH and The FIDA demonstration is a three year pilot between NYS DOH and CMS

Through a single monthly capitation, managed care plans will be g g y p g presponsible to provide and pay for all medical services (Medicare and Medicaid)


What is FIDA?

Primary FIDA – Dual eligibles, age 21 and over that require community based long term care services for more than 120 days whocommunity-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


What’s the Size of the FIDA Market?

There are approximately 750 000 Medicare and Medicaid Estimated NYS Dual Eligible Market

I di id l I di id l 750,000 Medicare and Medicaid dual eligibles in the State of New York

Overall

Individuals receiving long term care in

institution

Individuals receiving long term care in

home & community

Approximately 180,000 individuals receiving long term care services in home

NYC AreaDuals 460,000 55,000 125,000

UpstateDuals 290,000 30,000 100,000care services in home,

community, and institutional settings are eligible for enrollment into FIDA

, , ,

NYS Duals 750,000 85,000 225,000

enrollment into FIDA

*Membership projections based on NYSDOH FIDA Demonstration Proposal** Began November 2012 Began November 2012


FIDA Goals

Improve Health

Enhance Quality and Access

R d d C t l C t Reduce and Control Costs


FIDA – What’s New & Improved?

Enhanced benefit package

Enhanced service delivery system Person-centeredness, consumer direction, needs assessment,

ltidi i li l i d di ti ti i tmultidisciplinary care planning and coordination, participant protections, continuity of care, Health Information Technology, evidence-based practice, and quality improvements

Focus on access to services Interdisciplinary team members playing a critical role in ensuring

appointments are made and kept prescribed care is timelyappointments are made and kept, prescribed care is timely delivered, and access challenges are minimized

Integrated appeals processg pp p



Integrated Information

A key challenge for dual eligibles is the absence of a single source of information explaining the scope of coverage and how to access servicesservices

FIDA will provide a single set of informative materials, streamline all marketing materials and all participant noticesmarketing materials and all participant notices

Plans will have access to all of a members data

Consolidated systems



Model of Care & Care Management

Builds off the strengths of the Medicare Advantage Dual Eligible Special Needs Plan Model of Care

Builds off the strengths of the MLTC Model of Care

Focuses on providing the right service at the right time Focuses on providing the right service at the right time

Integrates the programs so Medicare and Medicaid dollars can be spent interchangeably and result in a net savings p g y g


Before FIDA

COORDINATION OF CARE PAYMENT

MemberMEDICARE

SNF

Informal SupportsCommunity

CenterFamily Religious

Centers

HOSPITAL

MD

Personal Care

SNF Home Care

Long Term Care

CenterMEDICAID

MENTAL HEALTH

HOME CARE

PhysicianHospitalSpecialist

Acute Care

HOME CARE

Specialist


After FIDA

COORDINATION OF CARE PAYMENT

Home & C itPCP & FIDA #1

SNFCommunity Based Services

HospitalsFamilySupports

PCP &Specialists

FIDA #1

FIDA #2HOSPITAL

MDMember

Nursing Homes

Managed Care Plan

FIDA #3 MENTAL HEALTH

HOME CARECHHA

Long Term Care

ParaProfessional

services

HOME CARE


Benefit Design

FIDA plans will provide all services covered by Medicare Part A, B, and Pharmaceutical (D)Pharmaceutical (D)

Nearly all Medicaid State Plan physical health, behavioral health, and long term supports and services

An array of additional long term supports and services and Health and Wellness services not presently covered by the traditional Medicare or Medicaid programsp g

FIDA plans will coordinate, but FFS will continue to pay for:

Medicare and Medicaid Hospice services

Out of Network Family Planning services

Directly Observed Therapy for Tuberculosis

Methadone Maintenance Treatment


Enrollment Timeline

Community Residents SNF Residents Eligible community-based LTSS individuals

will be informed no earlier than April 1, 2014 of the opportunity to opt into a FIDA Plan for coverage starting no earlier than July 1, 2014

Eligible SNF-based LTSS individuals will be informed no earlier than July1, 2014 of the opportunity to opt into a FIDA Plan for coverage starting no earlier than October 1, 20142014.

April 2014, approved FIDA plans will be able to begin marketing and enrolling eligible members for a July 2014 effective date

2014.

July 2014, approved FIDA plans will be able to begin marketing and enrolling SNF residents for a October 2014 effective datemembers for a July 2014 effective date

July 1, 2014 initial membership in FIDA becomes effective

residents for a October 2014 effective date

October 1, 2014 initial membership in FIDA for SNF residents becomes effective

If you enrolled in an iSNP, you will not be

Beginning no earlier than July 1 2014, eligible community-based LTSS individuals will be notified of the State’s plan for passive enrollment, which would begin no

y , ysubject to passive enrollment

Beginning no earlier than October 1 2014, eligible community-based LTSS individuals will be notified of the State’s plan for passive enrollment which would begin noearlier than September 1, 2014. passive enrollment, which would begin no earlier than January 1, 2015.


Proposed Enrollment Process

Eligible dual eligibles would be enrolled into the FIDA program with the assistance of an Enrollment Brokerassistance of an Enrollment Broker

MLTC members will be passively enrolled into a FIDA

FIDA plans have NO role in the enrollment

Enrollment will be done through the MAXIMUS broker

The enrollment process will rely on a “conversion in place” approach under which duals enrolled in MLTCP plans will see their Medicare benefit added to their managed care plan’s portfolio

At any time, members will be able to op-out of the Medicare managed care product and retain their fee for service Medicare coverage


Reimbursement

The FIDA plan rates have yet to be set

The rates will be based on the MLTCP and Medicare Advantage risk adjusted methodologies

Proposed Reserve Requirements Include:

5.00% reserves for 2014


8 25% reserves for 2016 8.25% reserves for 2016



DOH SNF Work Group

DOH has convened a workgroup of nursing home operators, plans and advocates to work through outstanding issues relating to theadvocates to work through outstanding issues relating to the implementation of managed care for nursing homes

Workgroups areas include: Workgroups areas include:

Finance

Quality & Access

Network

Workgroup deliverables will be finalized before the year’s end


FIDA Proposal Status

The FIDA proposal was recently approved by CMS

NYSDOH finalized the Memorandum of Understanding (MOU) with CMS

CMS-NYSDOH-Plan 3-way contract will be completed late 2013/early 2014

25 preliminary plans have been identified to participation in the FIDA demonstration


Preliminary Plan Selection

Aetna Better Health of New York HHH Choices Health PlanAgeWell New York HIP/EmblemAgeWell New York HIP/EmblemAlphaCare of New York Independence Care SystemAmerigroup New York Integra MLTCAmida Care MetroPlus Health PlanArchcare MontefioreCenterLight Healthcare North Shore-Long Island Jewishg gCenters Plan for Healthy Living Partners Health Plan (OPWDD FIDA)Elderplan Senior Whole Health of New YorkElderServe Health UnitedHealthcare of New YorkElderServe Health UnitedHealthcare of New YorkFidelis Village Care of New YorkGuildNet VNS Choice


HealthFirst WellCare of New York

32

Agenda

Market Dynamics

MLTC Update

FIDA Overview



Case Studies


MOU Implications – Rate

The nursing home certifiable rate cell will be paid for individuals who meet the standard of nursing home level of care as defined by the NYSDOH Approvedstandard of nursing home level of care as defined by the NYSDOH Approved Assessment Tool

One rate cell for nursing home certifiable individuals will be determined for the entire Demonstration Area

Rate cells will be risk adjusted for each FIDA Plan by comparing each Plan’s relative risk for each rate cell to the regional average risk

For nursing facility services that are part of the traditional Medicaid benefit For nursing facility services that are part of the traditional Medicaid benefit package, FIDA Plans will be required to pay non-contracting providers the Medicaid FFS rate

Quality with hold: Quality with-hold:

Year 1: 1% Year 2: 2% Year 3: 3%


MOU Implications – Network

State Medicaid standards shall be utilized for community-based and facility-based long-term care supports and services (LTSS)pp ( )

In no instance may any FIDA Plan’s network have less than two of any provider type necessary to provide covered services

The following minimum access standards apply to facility-based LTSS services: g pp y y

For “new to service” Participants (meaning those not already receiving facility-based LTSS), FIDA Plans must enter into contracts or make payment arrangements with nursing facilities as meets the minimum access standards outlined for all providers in this section and as further outlined in the Three-Way Contractoutlined in the Three Way Contract

For Participants that are not new to services but are transitioning from a MLTC plan, from another FIDA Plan, or from Medicare and/or Medicaid FFS, FIDA Plans must either enter into contracts or make other payment arrangements with all nursing facilities in the Demonstration Area to ensure Participants’ residency and access to services are not interruptedDemonstration Area to ensure Participants residency and access to services are not interrupted

Participation of nursing facilities in the Demonstration may be subject to quality standards as articulated in the Three-way Contract


MOU Implications – Contracting

By December 1, 2014 FIDA plans will be required to develop a plan for fully integrated payment system through which providers would nofully integrated payment system through which providers would no longer be paid on a traditional fee-for-service basis, but would instead be paid on an alternative basis e g pay for performance or bundled payments e.g., pay for performance or bundled payments

After State approval and no earlier than January 2015, FIDA Plans will be required to implement the approved plans which will remain inbe required to implement the approved plans, which will remain in effect throughout the duration of the Demonstration


Agenda

Market Dynamics

MLTC Update

FIDA Overview



Case Studies


What Was

SNF RESIDENT LONG TERM CARE DUAL ELIGIBLE INSURANCE COVERAGE OPTIONSCOVERAGE OPTIONS

MEDICARE MEDICAID

NYC Fee for ServiceMedicare Advantage

Fee for ServiceMLTCMedicare Advantage MLTC

UPSTATE Fee for ServiceMedicare Advantage

Fee for Service


The New NormalSNF RESIDENT LONG TERM CARE DUAL ELIGIBLE INSURANCE

COVERAGE OPTIONS MEDICAID MEDICARE

Fee for Service MLTC Fee for Service Medicare Advantage iSNP FIDA

(no new entrants 1/1/14) (no new entrants 1/1/14)

NYC (no new entrants 1/1/14)

(no new entrants 4/1/14)

UPSTATE

(no new entrants 4/1/14) (no new entrants 4/1/14)


39


Fee for Service Conventional reimbursement for every service provided

Capitation Capitation Lump sum payment for each enrolled member, per period of time,

whether or not that person seeks care or uses services

Performance Bonuses Conditional income, paid out only if certain operational, quality or , p y p , q y

financial measures are met



Gain Sharing Assumes some financial responsibility for the profit and none for

the potential loss in serving members

Partial Risk Assumes some financial responsibility for the profit and the

potential loss in serving memberspotential loss in serving members

Full Risk Assumes full financial responsibility for the profit and the potential

loss in serving members


Agenda

Market Dynamics

MLTC Update

FIDA Overview



Case Studies


Case Study #1

What: MLTC and Fee for Service Medicare

Who: All new long-stay dual eligible SNF entrants as of 1/1/14

Where: Throughout NY State

When: As early as tomorrow

How: Medicare FFS

MLTC capitation

MLTC pays a performance bonus on quality measures


Case Study #2

What: MLTC and iSNP

Who: Any long stay dual eligible- voluntary

Where: Throughout NY State

When: As early as tomorrow

How: Medicare capitation & risk

MLTC capitation

MLTC pays a performance bonus on quality measures

Medicare pays a performance bonus on quality measures


Case Study #3

What: MLTC and FIDA

Who: Any long stay dual eligible- voluntary, opt out

Where: Metro NYC area

When: Mid to late 2014

How: Coordinated premium and benefit package

Medicare capitation

MLTC capitation

Risk bonus payment


Questions?

Steven HerbstDirector of Managed Care

[email protected]

(212) 697-3000


getting to shared risk - leadingage new york to shared ris… · mltcp medicaid premium the...

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