Medicaid Redesign Proposals

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Transcript Medicaid Redesign Proposals

CIDNY New Yorkers for Accessible Health Coverage
October 18, 2011
Section 2703 of the Patient Protection and Affordable Care Act (ACA)
provides states, under the state plan option or through a waiver, the
authority to implement health homes.
• opportunity to address and receive additional federal support for
the enhanced integration and coordination of primary, acute,
behavioral health (mental health and substance use), and longterm services and supports for persons with chronic illness.
• provides 90 percent FMAP rate for health home services for the
first eight fiscal quarters that a health home state plan amendment
is in effect; multiple SPAs permitted.
At least two chronic conditions, one chronic condition and at risk for
another, or one serious and persistent mental health condition.
Chronic conditions include but are not limited to:
mental health condition
substance abuse disorder
heart disease,
being overweight (BMI over 25)
Enrollees in the behavioral health category will be identified through claims and
encounter data. They often have co-morbid chronic, medical conditions and unmet
social needs such as a lack of permanent housing
Enrollees in the chronic medical condition category will be identified through claims
and encounter data as having two or three chronic medical conditions – including
The State will use a combination of clinical risk groups (CRG), an algorithm that
predicts hospitalizations, and behavioral health indicators to select Medicaid
enrollees for health homes.
• Developmental
• Long Term Care
• 209,622 Recipients
• $4509 PMPM
• 52,118 Recipients
• $10,429 PMPM
Total Complex
$2,338 PMPM
32% Dual
51% MMC
$6.5 Billion
50% Dual
10% MMC
$25.9 Billion
$6.3 Billion
16% Dual
61% MMC
• Mental Health and/or
Substance Abuse
• 408,529 Recipients
• $1,370 PMPM
$10.7 Billion
77% Dual
18% MMC
$2.4 Billion
20% Dual
69% MMC
• All Other Chronic
• 306,087 Recipients
• $698 PMPM
“Medical Home” for Patients with Risk Score ≥50
Based on Prior 2-Years of Ambulatory Use
"Medical Home" Status
Occasional User
No PC/Spec/OB
Number of
Source: NYU Wagner School, NYS OHIP, 2009.
Must be enrolled (or be eligible for enrollment) in the NYS Medicaid program and
agree to comply with all Medicaid program requirements.
Can either directly provide, or subcontract for the provision of, health home
services. Responsible for all health home program requirements, including services
performed by the subcontractor.
Care coordination and integration of heath care services will be provided to all health
home enrollees by an interdisciplinary team of providers, where each individual’s care is
under the direction of a dedicated care manager who is accountable for assuring
access to medical and behavioral health care services and community social supports
as defined in the enrollee care management plan.
Must meet standards for delivery of six core health home services as described in
following slides. Must provide written documentation that clearly demonstrates how
the requirements are being met.
Health home providers will be required to provide the following health home
services in accordance with federal and State requirements:
Comprehensive care management
 An individualized patient centered care plan based on a comprehensive health risk assessment – must
meet physical, mental health, chemical dependency and social service needs.
Care coordination and health promotion
 One care manager will ensure that the care plan is followed by coordinating and arranging for the provision
of services, supporting adherence to treatment recommendations, and monitoring and evaluating the
enrollee’s needs. The health home provider will promote evidence based wellness and prevention by
linking patient enrollees with resources for smoking cessation, diabetes, asthma, hypertension, self-help
recovery resources, and other services based on need and patient preference.
Comprehensive transitional care
 Prevention of avoidable readmissions to inpatient facilities and oversight of proper and timely follow-up
Patient and family support
 Individualized care plan must be shared with patient enrollee and family members or other caregivers.
Patient and family preferences are considered.
Health home providers will be required to provide the following health home
services in accordance with federal and State requirements:
Referral to community and social support services
 Provider will identify and coordinate community and social supports
Use of health information technology (HIT) when feasible
 Health home providers will be encouraged to utilize RHIOs or a qualified entity to access
patient data and to develop partnerships that maximize the use of HIT across providers.
Health home provider applicants must submit a plan with their application for achieving
compliance with the final health home HIT requirements within 18 months of program
NY will be using quality measures that fall into the following categories:
Measures collected from claims and encounters
Measures currently collected by managed care plans
Measures per NQF and/or meaningful use measures
New measures that meet federal reporting requirements
NY will use “designated providers” for the Health Home Program
Designated providers can be:
Managed Care Plans
Medical, mental and chemical dependency treatment clinics
Federally Qualified Health Centers (FQHCs)
Targeted Case Management (TCM) programs
Primary care practitioner practices
Patient Centered Medical Homes (PCMHs)
Any other Medicaid enrolled entity that meets NY’s health home requirements
Considering adding other long term care providers
NY is seeking applicants that :
◦ have strong medical, behavioral, and social service community providers connections
◦ use multi-disciplinary teams of medical, behavioral , TCM, and social services providers that can
assure appropriate and timely access to services.
Each patient enrollee will be assigned a single care manager who is responsible for
managing and coordinating their care. There will be only one care plan for each patient
enrollee. All members of the health home team will report back to the care manager on
patient status, treatment options, actions taken, and outcomes.
Health homes will be responsible for reducing or eliminating costs associated with avoidable
inpatient and emergency room visits and improving patient outcomes.
976,000+ high cost/high need
Medicaid enrollees
(1) Chronic conditions
at risk for a 2nd
chronic condition
(2) Chronic
(1) Serious &
Persistent Mental
Health Condition
*Medically and Behaviorally
Patient Meets
Health Home
Non-Compliant with Treatment
Health Literacy Issues
ADL Status
Inability to Navigate Health Care
Social Barriers to Care
Assigned a
Health Home
Temporary Housing
Level I Health Home
Services –
Moderate Need
Level II Health Home
Services – Multiple
Complex Needs
Lack of Family or Support
System Food , Income
Need assistance applying for
Entitlement Programs
Level III Health Home
Services –
Intensive Complex Needs
Periodic Reassessment *
for continuation of Health Home Services
Health Home Services
Not Required
Primary Care
The State will use a combination of the following to assign Medicaid enrollees
to Health Homes:
◦ clinical risk groups (CRG),
◦ an algorithm that predicts hospitalizations, and
◦ behavioral health indicators
Medicaid enrollees will be assigned to a health home, to the extent possible,
based on existing relationships with ambulatory, medical and behavioral health
care providers or health care system relationships, geography, and/or
qualifying condition.
Initial assignments will be for members who qualify for Health Home services
but currently do not have a meaningful primary care or case management
Patients will not be moved from their current TCM/COBRA, CIDP, MATS
The State will also include any supportive housing services an individual may
have in keeping those connections in health home assignments.
Once assigned, enrollees will be given the option to choose another provider
when available, or opt out of health home enrollment.
The State will provide health home providers a roster of assigned enrollees
and current demographic service access information to facilitate outreach and
With the exception of TCMs, where special arrangements may be made,
Medicaid members enrolled with plans will be assigned into Health Homes by
the plan utilizing loyalty and attribution data provided by the state.
165 LOIs received
Many comprehensive well thought through networks
Some concerns about specific network adequacy issues
Some LOIs have more comprehensive networks than others
Some overlapping regions and partners
Some smaller less robust entities that should merge
DOH is working with OMH, OASAS and NYCDOHMH to
assess network adequacy and suggest additional
network partners and any appropriate mergers
Phase I - 13 counties:
◦ Bronx, Kings (Brooklyn), Nassau, Monroe, Warren, Washington, Essex, Hamilton, Saratoga, Clinton, Franklin, St.
Lawrence, Schenectady
◦ HH application due date for Phase I counties only is November 1, 2011.
◦ Implementation is scheduled for January 1, 2012
Phase II** – 14 Counties:
◦ Manhattan, Queens, Richmond (Staten Island), Suffolk, Westchester, Rockland, Orange, Putnam, Dutchess,
Ulster, Sullivan, Erie, Albany, Rensselaer
◦ HH application due date for Phase II counties only is February 1, 2012.
◦ Implementation is tentatively scheduled for April 16, 2012.
Phase III** – 35 Counties:
◦ Alleghany , Cattaraugus, Chautauqua, Niagara, Genesee, Orleans, Wyoming, Livingston, Ontario, Broome,
Cortland, Cayuga, Chenango, Oswego, Jefferson, Madison, Steuben, Schuyler, Chemung, Yates, Seneca, Wayne,
Tioga, Fulton, Oneida, Otsego and Onondaga, Montgomery, Columbia, Greene, Delaware, Schoharie, Lewis,
Herkimer, Tompkins
◦ HH application due date for Phase III counties only is April 21, 2012.
◦ Implementation is tentatively scheduled for June 18, 2012.
**Please note that Health Homes approved to provide Health Home services under Phase I will need to resubmit their
application with updated information for Phase II and III if they plan to provide Health Home services to Medicaid
enrollees in these counties.
Finalizing roles of responsibilities for managed care plans
Targeted Care Management transition
Network adequacy review and feedback
Final CMS SPA roles (outreach and engagement; quality
Rate adequacy feedback (HIV upweights, etc.)
NYS Health Home Web site (links to many relevant
Questions and/or comments regarding New York's
implementation of health homes can be directed to
[email protected].