Medicaid Redesign

in New York State:

Managed Long Term Care
in Nursing Homes

Acronyms
Dual Eligible = Someone who has Medicare &
Medicaid
TYPES OF PLANS/ Agencies
MLTC Managed Long Term Care
MA Medicare Advantage OR Medicaid Advantage
MAP Medicaid Advantage Plus
PACE Program for All-Inclusive Care for the Elderly
LDSS Local Dept. of Social Services/ Medicaid
program
DOH NYS Dept. of Health
Managed Care Concepts in Dual Eligible plans
Full Capitation Rate covers all Medicare & Medicaid
services (PACE & Medicaid Advantage Plus)
Partial Capitation Rate covers only certain
Medicaid services MLTC package of long term
care services

Continued
TYPES OF SERVICES
CBLTC - Community-Based Long-Term Care services
LTC Long Term Care generally also known as
o LTSS Long Term Services & Supports
PCS or PCA Personal care services Personal Care Aide
CDPAP or CDPAS Consumer Directed Personal Assistance
Program
CHHA Certified Home Health Agency
ADHC Adult Day Health Care (medical model)
o SAD or SADC Social Adult Day Care
PDN Private Duty Nursing
Waiver programs Home & Community Based Services
(HCBS)
o Lombardi Long Term Home Health Care Program
o TBI Traumatic Brain Injury waiver
o NHTDW Nursing Home Transition & Diversion Waiver
o OPWDD Office of Persons with Developmental
Disabilities Waiver
DOH NYS Dept. of Health
GIS type of DOH directive
DSS or LDSS local Dept. of Social Services

The Issue

The U.S. spends more on health care - both

per capita and as percentage of gross
domestic product (GDP) than other nations
do.
The US spends 16% of its GDP on healthcare
nearly double all other countries
New York specifically spent nearly double the
national average per recipient
Unless this is changed the Medicaid program
in New York will no longer be sustainable

From 2006 to 2011 alone New York State Medicaid

spending increased by 14 Percent to $52.9B

The Solution: Redesigning New Yorks Medicaid

Program
Governor Cuomo created the MRT to redesign
New Yorks Medicaid program in January 2011
to ensure that it was sustainable.
One overarching theme of the redesign team
proposals is to move all Medicaid recipients
from Fee for Service reimbursement to
Managed Care.
Broome County Social Services is NOW a
Mandatory Medicaid Managed Care County.
o Managed Care enrollment is currently mandatory for Community
Medicaid and Family Health Plus eligible individuals in Broome
County

The Issue: Fee for Service vs Managed Care

Fee for Service (FFS)

Managed Care

Who does Medicare or Medicaid Pays each provider fee for each

Pays flat monthly fee (capitation)

pay?
Who does provider bill?

service rendered
Provider bills Medicare or

to insurance plan
Bills the managed care plan,

Medicaid directly

which pays from a monthly

capitation rate from Medicare or

Providers available

Any provider who accepts the

Medicaid
Only providers in the insurance

Permission needed for services?

insurance (e.g. Medicare)

Sometimes. In Medicaid, need

plans network
Often. Plan may require

approval for personal care,

authorization to see specialists,

CDPAP, etc. but not for all

or for many services. May not

Policy incentive to give too

medical care.
Incentive to bill for unneces-sary

go out of network.
Plan has incentive to DENY

much/ too little care?

care. But offset when

services, and keep part of

authorization needed for

capitation rate for profit.

services like Medicaid personal

What package of services is

care.
Original Medicare = all Medicare Package of services may be

available?

services.

partial (MLTC) or full (PACE =

all Medicare & Medicaid
services).

What is Managed Care?

Managed-care organizations (MCOs) serve as an
integrating mechanism because they combine
the insurance and service delivery functions of
health care.
Managed care delivers coordinated health care
services and supports through a network of
providers.
o Attempting to fix the disconnect of all the necessary
services one needs for a better quality of life.

Vision for Health Care

System Redesign
Improving the quality of care by focusing on
patient-centered care, timeliness, efficiency and
equity.
Improving health by addressing root causes of
poor health e.g., poor nutrition, physical
inactivity, and substance use disorders.
Bend the Medicaid cost curve by reducing per
capita costs
Ensure access to quality care for all Medicaid
members.

Delivery System Reform

Incentive Payments (DSRIP)
MRT Waiver the waiver allows the state to
reinvest over a five-year period $8 billion of the
$17.1 billion in federal savings generated by MRT
reforms
The DSRIP program promotes community-level
collaborations and focuses on system reform.
o Their main goal is to achieve a 25% reduction in
avoidable hospital use over five years.

Safety net providers will be required to

collaborate to implement innovative projects
focusing on system transformation, clinical
improvement and population health
improvement.

A prospective enrollee has a choice of three

Managed Long Term Care Models:
Partially Capitated Managed LTC (Medicaid)
Benefit package is long term care and ancillary
services including home care, unlimited nursing
home care
Program of All-Inclusive Care for the Elderly
(PACE) (Medicare and/or Medicaid)
Benefit package includes all medically necessary
services primary, acute and long term care ( Must
be nursing home eligible)
Medicaid Advantage Plus (MAP) (Medicare and
Medicaid)
Benefit package includes primary, acute and long
term care services (Must be nursing home eligible,
also excludes some specialized mental health
services)

MLTC Enrollment
Who is required to enroll in
MLTC?
o Dual Eligible Medicaid beneficiaries
o Age 21 and over
o Require long term care services for
more than 120 days
Community Based Long Term Care Services
(i.e. Personal Care, Nursing, ADHC, Therapy)

MLTC Enrollment

Applicant must choose a plan and a

primary care provider (PCP) within 60 days
for MLTC.
o Mandatory Notice - sixty day choice period
begins with this notice
o Auto Assignment - if the consumer does not
choose a plan within 60 days, one will be autoassigned for them using the states approved
algorithm

9 month lock-in period begins after first

90 days of enrollment and applies with
every new enrollment

4 Big Changes Managed Care & LTC

Change

Description

Fed Approval/Status

MLTC Managed
Long Term Care

Dual eligibles age 21+ access to most

home care services is solely through
an MLTC, PACE or Medicaid
Advantage Plus plan in NYC & 9 other
counties

CMS approved 1115

Waiver expansion 9/2012,
started NYC/Metro area,
rolling out Statewide 201314

Nursing home care

carved into
managed care
package

Both Dual eligibles in MLTC plans

and non-duals in Mainstream
Medicaid managed care plans must
access nursing home care through
plan, rather than fee for service.

CMS approval pending for

June 2014 start roll-out
downstate, then Dec. 2014
Upstate

Mainstream
managed care
carve-in PCS,
CDPAP, PDN

Non-dual eligibles STATEWIDE in

mainstream Medicaid managed care
must get personal care, CDPAP,
private duty nursing thru MC plans

CMS approved for PCS/

CDPAP eff 8/2011
STATEWIDE/ nursing
home will start 6/2014

FIDA Fully
Integrated Dual
Advantage

Dual Eligible MLTC members in

NYC, Long Island & Westchester will
be passively enrolled into FULL
CAPITA-TION FIDA managed care

11/13 CMS reached

Memorandum of
Understanding with
SDOH. CMS now doing

Fully Integrated Duals

Advantage Program (FIDA)
FIDA plans are fully capitated plans similar to
Medicaid Advantage Plus. They will control all:
o Medicaid services including long term care now covered by
MLTC plans PLUS other Medicaid services NOT covered by
MLTC)
o Medicare services ALL primary, acute, emergency, behavioral
health, long-term care

Who will be affected by this?

o Adult dual eligibles who are receiving or applying for either:
MLTC, MAP or PACE services (125,000 people) OR
Nursing home care (55,000 people), but
EXCLUDES people in TBI, NHTDW, OPWDD waivers,
hospice, Assisted Living Program.

When?
o Roll-out begins Oct. 1, 2014 (pushed back 6 months on Jan. 16,
2014). Demo ends Dec. 2017.

Nursing Home Transition Issues

Contracts with MCOs getting them
and agreeing on terms
Partnering with plans and hospitals
Understanding the facilitys role vs.
the MCOs role in managing care
Educating staff
o Admissions, Social Work, Case Management, Billing

Educating Families
o NY Medicaid Choice (http://www.nymedicaidchoice.com/)

Impact on YOU!
Contract negotiation with MCOs
Admission and discharge
practices
Case Management skilled staff
required!
Communication

Questions?