Transcript Empire Justice Center

Accessing HIV
Services Under
Medicaid Redesign
Webinar Sponsored by:
The NYSDOH AIDS Institute
September 29, 2014
Presented by: Amy E. Lowenstein
Senior Attorney
Empire Justice Center
© 2014 Empire Justice Center
Agenda
 Major changes to service delivery
• Ongoing expansion of Medicaid Managed
Care
• New programs being created
 What does this mean for people living
with HIV/AIDS?
• Case example
• Advocacy strategies
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Acronyms Abound
BHO – Behavioral Health Organization
DISCO - Developmental Disabilities Individual
Support and Care Coordination Organization
FIDA – Fully Integrated Dual Advantage plan
HARP – Health and Recovery Plan
HH – Health Home
MLTC – Managed Long Term Care
MMC – Medicaid Managed Care
PCP – Primary Care Provider
SNP – Special Needs Plan
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Managed Care for All:
The Fundamental Driver
of Change in NYS
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Ongoing Expansion of
Medicaid Managed Care
Virtually all populations and services are shifting
into MMC when DOH deems appropriate
Populations still in fee for service include
dual eligibles, spend down & third party coverage
folks, people in waivers programs (TBI, NHTD)
Services still in fee for service include
nursing home, mental health and substance
abuse services … for now!
Implementation Schedule on MRT website:
https://www.health.ny.gov/health_care/medicaid/redesign/care
_management_for_all.htm
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Special Care Management
Programs
 HIV SNPS
 Health Homes (HH)
• Enrollees can be Fee for Service or MMC
• HHs absorbed targeted case management
 Behavioral Health Organizations (BHOs)
 Managed Long Term Care (MLTC)
 Coming Soon:
• Fully Integrated Duals Advantage (FIDA) (1/1/15)
• Health and Recovery Plans (HARPs) (4/1/15)
• Developmental Disability Individual Support and
Care Coordination Organizations (DISCOs)
(10/1/15)
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Health Homes
 For those with chronic conditions in need of
intensive care management
 Services include engagement, tracking,
plans for care, care coordination
• HIV COBRA case management
• OMH and Addiction Treatment case management
 DOH or managed care plan makes
assignments; counties and CBOs can make
referrals
 Health Homes by county:
http://www.health.ny.gov/health_care/medicaid/prog
ram/medicaid_health_homes/contact_information/
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Behavioral Health in MMC
 Carve in for adult behavioral health
• April 1, 2015: NYC; October 1, 2015: Statewide
 3 ways MMCs administer behavioral health
1. As a “qualified” plan, or
2. In contract with a BHO/experienced vendor, or
3. As a HARP – specialized MMC for people with
significant behavioral health needs
 MMC plan must meet certain standards:
•
•
•
•
Network adequacy
Evidence based assessment tools
Adequate service penetration
Ensure that the provider drives services
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Managed Long Term Care (MLTC)
 Program for dual eligible adults in need
of more than 120 hours of long term
care
 Phased in across the state:
• Mandatory in half of the counties, including
NYC
• Other counties when capacity
 Consumer concerns include incentives
for community based care, impartial
assessments, due process rights
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Remaining MLTC Roll-Out Schedule
Transition Month
Counties
August 1, 2014
Dutchess, Montgomery, Broome, Fulton,
Schoharie
September 1, 2014
Delaware, Warren
October 1, 2014
Niagara, Madison, Oswego
November 1, 2014
Chenango, Cortland, Livingston,
Ontario, Steuben, Tioga, Tompkins,
Wayne
December 1, 20114 Genesee, Orleans, Ostego, Wyoming
January 1, 2015
February 1, 2015
Chautauqua, Chemung, Seneca,
Schuyler, Yates, Cattaraugus, Alleghany
Essex, Clinton, Franklin, Hamilton,
Jefferson, Lewis, St. Lawrence
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Fully Integrated Dual Advantage
 Demonstration project to coordinate care for
dual eligible population
 ONLY in NYC, Long Island, Westchester
 FIDA provides all Medicare & Medicaid
services
• Person-centered care model
• Integrated appeals process
 MLTC recipients will be “passively enrolled”
into a FIDA plan
• Passive enrollment effective April 2015
• Individuals can affirmatively decline (“opt out of”)
FIDA enrollment
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What Changed for People
Living with HIV/AIDS?
Case Example
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Samantha
 Samantha is living with HIV, receives
SSI, and is enrolled in Medicaid
 How does Samantha access:
• Primary care?
• Pharmacy?
• Dental care?
• Mental health counseling?
• Substance use disorder treatment?
• Home care?
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Primary Care under MMC
 Hopefully Samantha chooses an MMC
plan that includes her primary care
provider (PCP) in its network
• 30 days to choose a plan, 90 days to switch
• PCP makes referrals for other services
 Samantha and others with chronic
conditions like HIV have the right to:
• Have an HIV specialist serve as their PCP, or
• Get standing referral to HIV specialist, and
• Get care at an HIV specialty center
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Pharmacy under MMC
 Each plan has its own drug formulary
• Formularies must be comparable (not
identical) to Medicaid formulary. Link to
find plan formularies:
http://pbic.nysdoh.suny.edu/
 Samantha and her doctor also need to
learn her plan’s policies on:
• Prior authorization (all plans
use standard form)
• Quantity limits
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Prescriber Prevails in MMC
 Samantha’s doctor has the last word on
whether certain medications are medically
necessary (even if non-formulary)
 Prescriber prevails protections in MMC
apply to 8 therapeutic classes:
Anti-depressant
Anti-retroviral
Anti-rejection
Seizure
Epilepsy
Endocrine
Hematologic
Immunologic
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Dental Services under MMC
 Medicaid’s dental benefit narrowly
defined - only essential services
• Generally, three visits a year
• Primarily preventive services
• Tooth extractions favored over root canals
• Dentures replaced only every 8 years
 Prior authorization required
 Must use in-network
providers
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Mental Health & Substance Use
Disorder Services Currently
SSI-related
detox services
inpatient mental
health, outpatient
mental health,
inpatient
rehabilitation, detox
All other behavioral
health and
substance abuse
services
Continuing day
treatment, partial
day hospitalization,
outpatient chemical
dependency
Plan
Provides
Fee for
Service
Non-SSI-related
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Personal Care under MMC
 Samantha has to go through her plan
 Plan arranges for assessment and
makes the authorization
 Includes Consumer Directed Personal
Care
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What happens when
Samantha gets Medicare?
 At 65, Samantha will be Medicare eligible.
• Medicaid will pay her Medicare Part A & B
premiums.
• She will get Extra Help paying for her drugs
through Medicare Part D
 Samantha will become a dual eligible and
will be disenrolled from MMC
• Medicare will pay for most of her health services
• Medicaid will pay for services Medicare does not
cover
• If Samantha needs more than 120 days of long
term care, like home care or AIDS ADHC, she will
have to join an MLTC
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What if the MMC or
MLTC denies or
reduces services?
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Advocating for Access MMC
 Transitional care for new enrollees under
active treatment
• MMC plans must continue out-of-network care
for 60 days if disabling or degenerative
condition (or pregnancy).
http://www.wnylc.com/health/afile/58/76/
 Temporary Exemption from MMC
• To continue with a specialist who does not
take any MMC plan.
• Must have an existing ongoing care plan that
lasts at least 6 months
• Exemption ends after 6 months
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Advocating for Access MLTC
 90 day transition period for new MLTC
enrollees
• Entitled to continue long term care at the
same amount and level for 90 days.
• Includes, personal care, adult day
healthcare, private duty nursing and other
long term care
 No lock-in  can change MLTC
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Advocating for Access
MMC & MLTC
 Call the DOH Managed Care
Complaint Helpline: 800-206-8125
 Call the Long Term Care Ombuds
Program  Coming Soon!!
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Appeal Rights
 MMC & MLTC plans have internal and
external review processes
• Internal peer reviewers
• External review with State Dept. of
Financial Services
 Enrollees can request a fair hearing at
the same time, unless
• Enrolled in Managed Long Term Care*
 Enrollees can get aid-continuing
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Service Limits
 Orthotics & compression stockings – class
action challenging limits (Davis v. Shah)
 Occupational, Physical & Speech Therapy 20 visits per year cap
 Enteral therapy
• Exemption to limits expanded in 2012 to include
people with HIV.
• Standards for enteral therapy are in regulation:
https://www.health.ny.gov/regulations/recently_ad
opted/docs/2014-0430_coverage_of_enteral_formula.pdf
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Questions?
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For more information,
contact
Empire Justice Center
Health Technical Assistance
800-724-0490 x 5822
[email protected]
Amy E. Lowenstein, Senior Attorney
(518) 462-6831 ext. 2857
[email protected]
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Also visit: www.nyhealthaccess.org