Medicaid Redesign Proposals
Download
Report
Transcript Medicaid Redesign Proposals
Medicaid Managed Care
Program Changes
and Future Initiatives
April 27, 2011
NYAPRS 7th Annual Executive Seminar
on System Transformation
page 1
Administrative Actions Affecting Premiums
Reduce Profit From 3% to 1%
(Proposal #6)
Effective 4/1/11 Reduces surplus built into MMC and FHP rates
Amendment to Part 98 will be made to reduce contingent
reserve requirement as it relates to MMC and FHP lines of
business for 2011 and 2012, and tightens requirements for
equity withdrawals
Reduce Trend Factor 1.7%
(Proposal #8) Effective 4/1/11
Reduces projected 4/1/11 rate increase by 1.7% by reducing
trend factors for MMC and FHP
page 2
Eliminate Direct Marketing
(Proposal #10)
Effective 4/1/11
Contract Amendment to prohibit plans from
engaging in marketing activities; plans can
continue to do FE
Continue working with the industry to develop
the most equitable way to administer the
reduction as long as target is met.
page 3
Bundle Pharmacy into MMC
(Proposal #11)
Effective 10/1/11
Brings pharmacy benefit into MC benefit
package better aligning the overall benefit
package
Modest increases to existing co-pays for brand,
generic, and over-the-counter medications
Will work with the industry to promote a smooth
transition
page 4
Behavioral Health BHO & Integrated Models
(Proposal #93)
Manages FFS and current “carved out”
behavioral health services for all managed care
enrollees
Regional BHO’s responsible for medical
management and coordination of behavioral
health services
Future years risk models include integrated
delivery systems
page 5
Benefit limits/changes
Effective 4/1/11
Footwear (Proposal #30) Limited to children, diabetics, or
use in conjunction with a lower limb orthotic brace
Compression Stockings (Proposal #42) Limited to
pregnancy or treatment of open wounds only
Tobacco Cessation (Proposal #55)
Expands coverage to all women (not only pregnant
women) and men
6
counseling sessions within any 12 month contiguous
period
page 6
Benefit limits/changes
Effective 9/1/11
SBIRT (Proposal #83) Expands screening,
intervention, and referral to treatment for
alcohol/drug use beyond the ER setting to primary
health care settings
Effective 10/1/11
PT/OT & Speech (Proposal #34) Limit 20 visits in
12 month period, similar to current limits for FHP
page 7
Population and Benefit Expansion, Access to
Services, and Consumer Rights
(Proposal #1458)
Expand Managed Care Enrollment for non-dual eligibles
and modify mainstream benefit package
Access to Benefits and Consumer Protections
Streamline Managed Care Eligibility Process
page 8
Expand Enrollment & Modify Benefit Package
Expands enrollment of many previously exempt
& excluded populations over 3 years:
Year One – program ready
Enroll new populations
Exclusions – Recipient Restriction
Exemptions – HIV upstate, non-SSI SPMI/SED,
primary care/pregnant w/non-network provider,
temp out of district, language barrier, geographic
accessibility, chronic illness limit
Added benefit
Personal care
page 9
Expand Enrollment & Modify Benefit Package
Year Two
Enroll new populations
Exclusions – Infants<1200 gr., LTHHCP where
capacity, RRSY adolescents, nursing home
residents
Exemptions – LTHHCP look-alikes, ESRD, CIDP,
homeless
Added benefit
Nursing home services
page 10
Expand Enrollment & Modify Benefit
Package
Year Three
Enroll new populations
Exclusions- eligible for Medicaid buy-in for Working Disabled,
residents of State operated psychiatric centers*, blind or
disabled children living apart from parents for 30 days or more,
institutional foster care children*
Exemptions- residents of ICF/MR or ICF/DD and persons with
needs similar to these residents, Nursing Home Diversion and
transition waiver, resident of Long Term Chemical Dependence
programs*, Bridges to Health foster care waiver program*,
non-institutionalized foster care children, Medicaid Home and
Community-based Services Waiver recipients and individuals
with needs similar to the waiver recipients, Care at Home
recipients and individuals with needs similar to Care at Home
recipients
*enrollment contingent upon decisions regarding the benefit package
page 11
Access to Benefits and
Consumer Protections
Builds on current policies/procedures in place
Ensure adequate information for more chronic
populations being enrolled
How to access services
How to navigate managed care systems
Ensure plans have active language translation, including
TTY/TTD
Compliance with ADA
Ensure MCOs & providers are adequately trained in
covered benefits (ex. DME) & consistent w/ FFS
Modify Benefit Denial notices
page 12
Streamline Managed Care Enrollment Process
Mandates earlier choice of managed care plan during the
eligibility process
For new applications
Choice must be made during the application process
Similar to enrollment process for FHPlus
For persons newly targeted for mandatory enrollment
allows for 30 days to choose plan
If plan not chosen, current auto assignment algorithm followed
page 13
Accelerate State Assumption of Medicaid
Program (Proposal #141)
November 2010 Report to Governor for State
takeover of Medicaid Administrative Functions
Consolidate health plan contracts for Medicaid
Managed Care statewide
LDSS no longer to be involved in enrolling eligibles
into Managed Long Term Care plans
page 14
Mandatory Enrollment in MLTC and other
Care Coordination Models (Proposal #90)
Mandatory Enrollment Begins – April 2012
Elimination of NH Certifiable Requirement
Elimination of Designation Requirement
Provision for MLTC Partial Cap Expansion
Health Home Conversion
Establish Workgroup
page 15
Mandatory Initiative for April 2012
1115 Waiver approval needed from CMS
Require all dual eligibles who need community-
based long term care services for more than
120 days to enroll in Managed Long Term Care
or other approved care coordination models.
Elimination of Nursing Home Level of Care
Requirement upon Enrollment
Impact on Partials, MAP, PACE
Establish Documentation Requirements
Model Contract Amendments
MLTC and Care Coordination Model
page 16
Modify Role of LDSS in MLTC
Enrollment (Proposal #141)
MLTC Enrollment Criteria remains the same
until April 2012
Pre Enrollment Approval by LDSS will be
phased out for Partial Cap and MAP by Sept,
2011
Applicability to PACE will be explored with CMS
Model Contract Amendment Required
Revisions to plan materials must be processed
Training of Enrollment Broker/other Local
Entities
page 17
Dual Eligible Initiative
(Proposal #101)
Anticipate receipt of 18 month planning contract
with CMS for “State Demonstrations to
Integrate Care for Dual Eligible Individuals”
Conduct analysis of Medicare / Medicaid data
on Duals
Engage Stakeholders
Develop Demonstration Proposal and submit to
CMS for implementation in Year 3
page 18