Geriatric Mental Health Alliance of New York State
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1 spgpolicy Geriatric Mental Health Alliance of New York State October 30, 2014
2 Topics 1. New York State Medicaid Redesign Team 2. Managed Care for Special Populations Behavioral Health Long-Term Care 3. Health Home 4. Delivery System Reform Payment Plan 5. Geriatric BH Issues 2
3 New York State Medicaid Redesign Team Section I: NEW YORK STATE MEDICAID REDESIGN TEAM (MRT) 3
4 Overview New York State Medicaid Redesign Team (MRT): Created by Governor Cuomo in January Tasked with finding ways to reduce costs and increase quality and efficiency within the Medicaid program. Two major recommendations were enacted to drive the transition to managed care: New multi-year Medicaid Global Spending Cap. Care management for all Medicaid beneficiaries: Several different models. Will eventually provide fully-integrated managed care for all Medicaid enrollees. 4
5 Managed Section I: Care for Special Populations: NEW YORK STATE Behavioral Health MEDICAID REDESIGN TEAM (MRT) 5
6 Overview On March 21, 2014, RFQ released This process will: Incorporate the full BH benefit into mainstream MMC Create specialized HARP products Plans may pursue either option on their own, through a contract with a behavioral health organization (BHO), or through a partnership with another experienced vendor. 6
7 Quick Facts Geography: Reimbursement: Statewide Per member, per month capitated payment Timeline: Downstate: April 2015; Upstate: October 2015 Target Population: Downstate: 80,000 individuals; Upstate: 60,000 individuals Eligibility: Non-dual individuals 21 or over may be eligible for HARPs if they have a SMI or SUD diagnosis Scope of Services: Behavioral health services currently covered by Medicaid; and New community-based services that promote independence 7
8 Managed Section I: Care for Special Populations: NEW YORK STATE Long-Term Care MEDICAID REDESIGN TEAM (MRT) 8
9 Long-Term Care Plans Managed Long Term Care (MLTC) Fully Integrated Duals Advantage (FIDA) Program of All-Inclusive Care for the Elderly (PACE) Medicare Advantage Special Needs Plans (SNP) 9
10 FIDA Demonstration Background Overseen by the CMS Federal Coordinated Health Care Office and Center for Medicare and Medicaid Innovation Seeks to improve care, reduce cost, and coordinate benefits for the dual eligible population through alignment of Medicare and Medicaid financing streams The memorandum of understanding (MOU) between CMS and New York was signed August 26, 2013 New York is the 7 th state to finalize its participation in this demonstration program 10
11 Memorandum of Understanding New York State proposes to fully integrate services and provide care coordination to dual eligibles through a managed care capitated model The demonstration will target 170,000 full dual eligibles The eight county demonstration region includes: Bronx, Kings, Nassau, New York, Queens, Richmond, Suffolk, and Westchester 11
12 FIDA Eligibility Eligible populations: - Age 21 or older; - Entitled to benefits under Medicare Part A and enrolled under Medicare Parts B and D, and receiving full Medicaid benefits; and - Reside in a FIDA demonstration county Individuals must also meet one of the following three criteria: - Require community-based long-term services and services (LTSS) for more than 120 days; - Are Nursing Facility Clinically Eligible (NFCE) and receiving facilitybased long-term services and supports; or - Are eligible for the Nursing Home Transition and Diversion (NHTD) 1915(c) waiver 12
13 Interdisciplinary Teams (IDTs) Service planning, coverage determinations, and ongoing care management are conducted by an IDT IDTs include the following (as appropriate): The participant and/or an authorized representative and/or his/her designee; Designated care manager; Primary care physician (PCP) or a designee with clinical experience from the PCP s practice; Behavioral health professional or designee with clinical experience from the same practice; Home care aide or designee with clinical experience from the same agency; Nursing facility representative who is a clinical professional; Registered nurse who completed the participant s assessment; and Other providers either as requested by the participant/designee or recommended by IDT members 13
14 FIDA Covered Benefits All services covered by Medicare Parts A, B, and D; All Medicaid services including physical health, behavioral health, LTSS, and any others deemed medically necessary; and Additional services or items that address a participant s needs can be included in the PCSP at the plan s discretion Home care services must be provided through CHHA 14
15 Plans Participating in Readiness Review MLTC Enrollment for Plans Participating in FIDA Readiness Review # Plan Name MLTC Enrollment 1 VNSNY Choice 17,150 2 GuildNet 14,363 3 Senior Health Partners 11,242 4 ElderServe 10,369 5 Elderplan 10,120 6 CenterLight Healthcare 9,139 7 Fidelis Care at Home 6,999 8 WellCare 5,819 9 Independence Care Systems 5, AgeWell New York 3, VillageCare Max 2, Amerigroup 2,798 # Plan Name MLTC Enrollment 13 Aetna Better Health 2, HHH Choices 2, ArchCare 1, Centers Plan for Community Living 1, EmblemHealth 1, Integra 1, Senior Whole Health United Healthcare North Shore LIJ Health Plan MetroPlus AlphaCare Montefiore 339 * MLTC enrollment figures are limited to the eight county FIDA demonstration region and are current as of June ** MLTC enrollment figures and list of participating plans are from the DOH website. 15
16 Implementation Timeline New York City and Nassau County: Voluntary Passive Enrollment Date January 1, 2015 April 1, 2015 Suffolk and Westchester Counties: Voluntary Passive Enrollment Date April 1, 2015 July 1,
17 Health Section I: Homes NEW YORK STATE MEDICAID REDESIGN TEAM (MRT) 17
18 Overview A Health Home is a care management service model. All services are coordinated. Enrollees are assigned a care manager. Payment is flexible including structuring a tiered payment methodology. Health Home have role in HARP and DSRIP 18
19 Quick Facts Geography: Enrolled: Eligibility: Reimbursement : Scope of Services: Statewide 125,000 individuals (52,000 - outreach; 73,000 - active case management) Individuals with: At least two chronic conditions; or One qualifying chronic condition (HIV/AIDS or SMI) Per member per month engagement and case management payments adjusted for acuity Comprehensive care management; Care coordination and health promotion; Comprehensive transitional care; Individual and family support services; Referral to community and social support services; and Use of health information technology to link services 19
20 Examples: Designated Health Homes North Shore LIJ Health Home Bronx Lebanon Hospital Center Bronx Accountable Healthcare Network Health Home Coordinated Behavioral Care Inc. New York City Health and Hospitals Corporation New York and Presbyterian Hospital North Shore LIJ Health Home Maimonides Medical Center Visiting Nurse Service of New York Home Care 20
21 Delivery Section I: System Reform Incentive NEW YORK STATE Payment Program MEDICAID REDESIGN TEAM (MRT) 21
22 Medicaid Waiver On April 14th, NYS received approval from CMS on the Terms and Conditions of its $8 billion Medicaid waiver. 22
23 Medicaid Waiver The State s Medicaid Redesign Team waiver: Delivery System Reform Incentive Payment (DSRIP) Plan: $6.42 billion Interim Access Assurance Fund (IAAF): $500 million Other Medicaid Redesign: $1.08 billion Health Home development Behavioral health Workforce training 23
24 Moving Away from FFS Current System Encourages volume Fragmented Variable quality Costly No incentive to keep communities healthy Coordinated Data-rich High quality Patient-centered Focuses on population health Ideal System Encourages value 24
25 DSRIP Overview The new Delivery System Reform Incentive Payment (DSRIP) program provides funding for new initiatives by providers to improve care, reduce costs, and improve outcomes. The overall goal is to reduce avoidable hospitalizations and emergency department (ED) use by 25 percent over five years. Metrics for will include four measures of avoidable hospitalizations: Potentially Preventable Emergency Room Visits (PPVs); Potentially Preventable Readmissions (PPRs); Prevention Quality Indicators Adult (PQIs); and Prevention Quality Indicators Pediatric (PDIs). More than $6.42 billion will be made available over five years to public hospitals and safety net providers through this program. 25
26 *Health Home TCM, or ACT, or children in the HCBS waiver. DSRIP Attribution Model **RTF, RRSY, rehabilitative services for residents of a Community Residence, etc. Outpatient clinic, CDT, PROS, day treatment, MMTP, or outpatient rehabilitation. DD Residen:al (Waiver and IID) Day/Voca:onal Care Management (MSC or CAH) Ar:cle 16 Clinic Other OPWDD Waiver Services Nursing Home Nursing Home SMI/SUD Care Manager* Intermediate or Intensive Residen:al Care** OMH/OASAS Outpa:ent Treatment Freestanding Psychologist/ Psychiatrist Specialty Medical or BH Inpa:ent/ED All Others Health Home members PCP (if mee:ng u:liza:on standard) Other Primary Care Provider or Outpa:ent Clinic Emergency Department Inpa:ent 26
27 Quick Facts Geography: Eligible Applicants: Funding Categories: Additional Information: Statewide Public hospitals and safety-net providers; partnerships are highly encouraged Project types three focus areas: System improvement Clinical improvement Population-wide strategies Projects must: Demonstrate community need; Show a commitment to life-cycle change and a willingness to commit sufficient resources; and Represent a transformative change for the provider 27
28 Reform Section I: Issues Geriatric NEW YORK STATE Behavioral Health MEDICAID REDESIGN TEAM (MRT) 28
29 Geriatric BH Issues FIDA Implementation Carve in of Behavioral Services IDT Process Plan size and finance Dual eligibles Home Based Services Access to 1915i services Other Flexible Services Future of Medicaid Only MLTC Plans LTC Plans and Behavioral Health Readiness DSRIP Opportunities 29
30 Questions? Section I: NEW YORK STATE MEDICAID REDESIGN TEAM (MRT) 30
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