Transcript Managed Long Term Care: Status in 2014 and Preview of

FIDA: Fully Integrated Dual Advantage
& MLTC UPDATE
FIDA Demonstration Program
New York City and Nassau – Currently Enrolling
Suffolk and Westchester Counties – Delayed
Evelyn Frank Legal Resources Program, NYLAG April 20. 2015
2
What is FIDA?
• The Affordable Care Act has a lesser known initiative – 20+ states are
designing “Duals Demonstration” programs -- to test the concept of
combining Medicare and Medicaid into a single benefit
• In NY, the duals demo is called FIDA: Fully Integrated Dual Advantage.
NYS opted to use a Managed Care model – FIDA Is a type of managed
care.
• WHY? Feds and State want to control costs of dual eligibles AND improve
care coordination and quality of care, especially for dual eligibles
needing Medicaid long-term care services
• FIDA Plans must reduce costs compared to Fee-for-Service (FFS) by 1% in
Year 1, 1.5% in Year 2 and 3% in Year 3.
3
Dual Eligibles
• Dual Eligible – someone receiving both Medicare and Medicaid
• WHY do Medicare beneficiaries need Medicaid?
1. They are POOR – help with out-of pocket costs.
2. They need Long Term Care, dental, vision services not covered by Medicare.
• “Duals” represent only 18% of Medicaid recipients, but 46% of Medicaid
spending.
• FIDA addresses hope that enhanced “person centered” care coordination
will both improve outcomes and save money.
• Aims to control perverse financial incentives of FFS Medicaid/Medicare system
• frequent hospital readmissions
• revolving door between hospitals and SNFs
• FFS incentives to bill for unnecessary care
• Simplify web of insurance:
1.
2.
3.
MEDICARE: Medicare /Medicare Advantage + Part D + Medigap
RETIREE or VA coverage
MEDICAID: Fee-For-Service Medicaid + MLTC
4
Managed Care vs. Fee for Service
1.
FEE FOR SERVICE – like American Express card
• Original Medicare
or Regular Medicaid
• Client uses any provider that accepts Medicare or Medicaid – not
limited to any network
• Provider bills insurance (Medicare or Medicaid) directly
• Some services require “prior approval” but many don’t – if doctor
prescribes, insurance pays
2. MANAGED CARE – like having a MACY’s card only
• Medicare Advantage, MLTC, or mainstream Medicaid Managed Care
• Providers must be in-network, services & specialist referrals must be
approved by a Primary Care Provider (PCP)
• Provider bills managed care company, not Medicare or Medicaid.
• If client went out of network, provider may not get paid
• “ADVANTAGE” is Government Term for Managed Care –
5
Original Medicare vs.
Medicare Advantage
Original Medicare
Medicare Advantage
Type of Plan
Fee for Service
Managed Care
Administered By
CMS – Federal
Government
Private Insurance Plan
Access to Providers
Medicare Providers
throughout US
Plan Network (caution –
may be local, not good
for sunbirds)
Referral to Specialist
NOT required
YES – may be required
Prior Authorization for
Services
NOT required with some
exceptions
YES
Buy Medigap
Supplement?
Optional
Can’t use Medigap for
co-insurance or copays.
6
Medicare
(seniors and people
with disabilities)
vs.
Inpatient
Original
Medicare
Outpatient
Medicaid
(people with limited
finances)
Drugs
Long Term Care,
dental, glasses,
hearing aids
Part A
Part B
Part D
OR
Medicare Advantage
(“Part C”)
Medicaid FFS
+ MLTC
Since 2012: Dual eligibles who need more than 120 days of home care must
enroll in Managed Long Term Care (MLTC), with some exceptions
7
Medicare / Medicaid Options for Duals who
need Long Term Care
Medical care –
may choose
ORIGINAL
Medicare
Part A and Part
B + Part D
Medicare
Long
Term Care
Advantage
(voluntary)
Medicaid
Managed Long
Term Care
(mandatory)
FIDA
OR may
combine both
Medical and
Long Term Care:
Or
Medicaid
Advantage Plus
Or
OR
PACE
Medicare
Advantage
8
MLTC IS BUILDING BLOCK
OF FIDA
• Review and Status of MLTC
9
Who is enrolled in MLTC?
Since late 2012, MOST adult Dual Eligibles (age 21+) seeking
Medicaid home care on a long-term basis in NYC must enroll
in an MLTC plan – no more CASA or Lombardi. Includes
CDPAP and Private Duty Nursing.
2. As of Mar. 1, 2015 in NYC - # of recipients
1.
•
•
•
•
•
108,512 MLTC - includes over 50,000 transitioned from CASA, Lombardi
9,111 PACE & Medicaid Advantage Plus (MAP) plans
3,605 Home Attendant/Personal Care Level II (down from 40,000+)
1,061 Housekeeping (Personal Care Level I) (down from 5600)
179 Lombardi (Kids + last to send to MLTC)
STATEWIDE mandatory MLTC enrollment – the last few
counties upstate becoming mandatory in early 2015.
3.
•
135,028 – Total Statewide MLTC, PACE & MAP 4/1/2015
Data from http://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/ and
http://www.nyc.gov/html/hra/html/facts/hra_facts.shtml
10
Who is EXCLUDED from MLTC?
• Duals who may not enroll in MLTC even in mandatory county –
• In Traumatic Brain Injury, Nursing Home Transition & Diversion or Office
for People with Developmental Disabilities waivers
• Have hospice care at time of enrollment (but may stay in MLTC if enroll
in hospice once already in MLTC. MLTC Policy 13.18 (June 25, 2013)* or
• Live in Assisted Living Program
• Under age 18
• Needs are not extensive enough to qualify -- If need only --
• Housekeeping services – apply at HRA HCSP (See MLTC Policy 13.21*) (if have
housekeeping and then later need upgrade to home attendant, submit M11q
to HCSP – will get thru CASA. Eventually will be required to join MLTC.
• Social Adult Day Care services – not available thru Medicaid
• Who MAY enroll but not required? Age 18-21 with or without
Medicare, if would otherwise need Nursing Home
* Policies posted at http://www.health.ny.gov/health_care/medicaid/
redesign/mrt_90.htm .
11
Managed Long Term Care (MLTC) Benefit Package
(Medicaid services that must come from a managed care plan)
• Various types of home care (More than 120 days):
Personal Care (home attendant and housekeeping)
Consumer-Directed Personal Assistance Program (CDPAP)
Home Health Aide, PT, OT (CHHA Personal Care)
Private Duty Nursing
• Adult day care – medical & social
•
•
•
•
• Social day care alone is not enough for MLTC
• Medical alert button, home-delivered meals, congregate meals
• Medical equipment, supplies, prostheses, orthotics, hearing aids,
eyeglasses, respiratory therapy, Home modifications
• 4 doctors—Podiatry, Audiology, Dental, Optometry
• Non-emergency medical transportation
SeniorHealthChoiceWell-PlusCare
• Nursing home
MLTC Plan
John Doe
Member ID: 123456ABC
11
12
Combination Example 1
• Dual Eligible with Original Medicare Part D and MLTC
Medigap
Plan F
John Doe
Member ID: 123456ABC
SeniorHealthChoiceWellPlusCare
NOTE: Extra Help - Part D
subsidy is automatic.
MLTC Plan
John Doe
Member ID: 123456ABC
Medigap is optional
13
Combination Example 2
• Dual Eligible with Medicare Advantage and MLTC
MediChoice
Options Plus
Medicare Advantage
w/MedicareRx
John Doe
Member ID: 123456ABC
NOTE: Extra Help - Part D
subsidy is automatic.
NO Medigap allowed.
SeniorHealthChoiceWellPlusCare
MLTC Plan
John Doe
Member ID: 123456ABC
14
Capitation – Full vs. Partial
• Capitation is the term used for the monthly premium paid to a
managed care plan by Medicare and/or Medicaid
• MLTC is “Partially Capitated” –
• This means that MLTC plan is paid to provide only PART Of
services a Dual Eligible receives – primarily Medicaid longterm care services
• FIDA and Medicaid Advantage Plus are “FULL CAPITATION”
• The plan is paid to cover ALL Medicare and Medicaid services
15
What is FIDA?
WHAT? FIDA plans are managed care plans similar to Medicaid
Advantage Plus. They are FULLY CAPITATED.
They control and provide all:
• Medicaid services including LTC now covered by MLTC plans
PLUS other Medicaid services NOT covered by MLTC
• Medicare services – ALL primary, acute, emergency, behavioral
health, long-term care
• But not: Methadone maintenance, out of network family planning
services, direct observation therapy for tuberculosis, and
hospice care
• These will be offered through regular Medicare/Medicaid (i.e.,
government pays, not the plan
16
Who is eligible for FIDA?
To enroll in FIDA, either voluntarily or passively, you must be:
• Age 21 or older; and
• Entitled to Medicare Part A and enrolled in Parts B and D; and
• Receiving full Medicaid benefits; and
• Reside in Demonstration Area: NYC and Nassau County (Suffolk and
Westchester indefinitely delayed) and
• Need Long Term Supports and Services (LTSS) for more than 120
days, either because:
1. Newly permanently residing in a nursing home; or
2. Eligible for the Nursing Home Transition and Diversion Waiver (NHTD);
or
3. Enrolled in or will be enrolled in an MLTC or MAP plan.
• Excludes people in TBI, OPWDD waivers, hospice, Assisted Living
Program.
FIDA 3-Way Contract § 3.2.1 [p. 186], MOU § C.1.
What does FIDA cover?
• Short Answer: EVERYTHING
– Medicare + Medicaid
• Long Answer:
– Doctors
– Hospitals
– Lab Tests/ MRI
– Preventive care
– Prescription drugs
• Rehabilitation Therapy (PT,
OT, ST)
• Home Care (PCA, HHA,
CDPAP)
• Nursing Home (short-term
and long-term)
• HCBS Waiver Services (such
as NHTD and TBI Waivers)
– Over-the-Counter drugs
– Behavioral Health
17
FIDA 3-Way Contract, Appendix A-1 [p. 253]
18
FIDA Means One Card
SeniorHealthChoiceWellPlusCare
MLTC Plan
John Doe
Member ID: 123456ABC
Medigap
Plan F
John Doe
Member ID: 123456ABC
SeniorHealthChoiceWellPlusCare FIDA
FIDA Plan
John Doe
Member ID: 123456ABC
19
Passive Enrollment if Don’t “Opt Out”
• FIDA is not mandatory. You have the right to opt out. BUT if you
don’t opt out you will be “passively enrolled” into a FIDA plan.
• 100,000 MLTC members in NYC received notice of FIDA
• 41,906 have OPTED OUT
•
4,158 are enrolled in FIDA as of April 2015
• Almost 70,000 MLTC members in NYC & Nassau will
automatically be enrolled in a FIDA plan sometime in 2015 unless
they opt out
• April 1, 2015 - 2,500 MLTC members were AUTOMATICALLY ASSIGNED
•
•
•
•
to FIDA plans because they did not opt out.
April 1 – April 18th – 1,101 have disenrolled for May 1, 2015
May 1, 2015 - 3,733 MLTC members will be automatically assigned to
FIDA plans – because didn’t opt out
June – - Passive enrollment is SUSPENDED
July - September 2015 – estimated 30,000 MLTC members
will be passively enrolled
20
Opt-Out
• At any time prior to an individual's passive enrollment date,
he/she may choose to opt-out of FIDA
• Opting out ensures that the individual will not be passively
enrolled into a FIDA plan for the life of the three-year
Demonstration.
• Update: DOH said 4/20/15 that may STILL be passive enrolled
next year even if opted out now. Still being clarified.
• Individuals may opt out by calling either 1-800-MEDICARE or
N.Y. Medicaid Choice (855-600-3432).
• Within 1-2 weeks of completing the opt-out request, the
individual should receive written confirmation by mail
MMP Enrollment Guidance § 30.1.4(E) [pp. 20-21].
21
Voluntary Enrollment (“opt in”)
• FIDA-eligible individuals may voluntarily enroll in
FIDA at any time (as of April 15, 2015 – only in
NYC & Nassau, not yet in Westchester & Suffolk
because enrollment delayed there)
• There is no lock-in or open enrollment period;
individuals can disenroll or switch FIDA plans at
any time, effective the first of the next month
• Individuals can voluntarily enroll in FIDA even
after opting out of passive enrollment
MMP Enrollment Guidance §§ 40.2, 40.3 [pp. 41, 49]; Appendix 5: State-Specific FIDA
Enrollment Guidance for NY §§ 18-24 [pp. 9-12].
22
Which FIDA plan will MLTC members be
passively enrolled in?
• Most people will be passively enrolled in a FIDA plan offered by
the same company that operates their current MLTC plan. Note
– only if the FIDA plan serves the borough client lives in.
• The following MLTC plans do not have affiliated FIDA plans.
Members will be “intelligently assigned” to a FIDA plan that
contracts with the same home care agencies to maintain
continuity of care:
1. All of NYC: Extended MLTC; HHH Choices; Montefiore MLTC; UnitedHealth
2. Staten Island: Guildnet
3. Nassau and Suffolk County: Extended MLTC
• CAUTION: You are NOT matched to a plan that covers your
doctors – just your home care agency.
23
90 Day Grace/Transition Period
• For the first 90 days after enrollment – the “transition” period -- the
FIDA plan is required to allow you to see your doctors, even if they
are out of network.
• The FIDA plan must pay for all your current doctors and receive all your
current home care, prescription drugs and other services – even if your
providers are not in the FIDA plan’s network or the drugs are not on the
plan’s formulary.
• WARNING: Your doctor may not be willing to agree to the FIDA plan’s
terms. If that happens, your doctor will not be paid even in the first 90
days.
• Behavioral health services have a longer transition period -- FIDA
plans must continue covering out-of-network behavioral health
providers for an ongoing “episode of care” for up to 2 years.
• After Transition Period only FIDA plan’s network providers and
formulary drugs will be covered
24
2015 FIDA phased enrollment – NYC & Nassau
Program Announcement Letter Mailed
Dec
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
90 Day Notices NO LONGER Mailed!
60 Day Notices Mailed
30 Day Notices Mailed
Automatic Enrollment (but suspended in
JUNE, resumes July)
Program Announcement Letter Mailed March 1st
Suffolk and Westchester Delayed Indefinitely
25
Timing of Notices and Passive Enrollment:
Region 1 (non-SSI)*
60-Day
Notice
30-Day
Notice
Effective
Date of
Passive
Enrollment
Jan-Aug 2015 January
February
March
April 1, 2015
Sep-Nov 2015 February
March
April
May 1, 2015
Dec 2015 Jan 2016
April
May
July 1, 2015
Feb-Mar 2016 NOT USED
May
June
July 1, 2015
Apr-May
2016*
June
July
August 1,
2015
Medicaid
renewal
expires in
90-Day
Notice*
March
NOT USED
* See note on next slide.
* 90-Day notices no longer being sent, per DOH 4/20/2015
26
Timing of Notices and Passive Enrollment:
Region 1 (SSI)
Birthday
in
90-Day
Notice
60-Day
Notice
30-Day
Notice
Effective Date of
Passive
Enrollment
Jan-Mar
January
February
March
April 1, 2015
Apr-Jun
February
March
April
May 1, 2015
Jul-Sep
March
April
May
July 1, 2015
Oct-Dec
NOT USED
May
June
July 1, 2015
All others*
NOT USED
June
July
August 1, 2015
• Any other eligible individual that would have qualified for passive enrollment
between April 1, 2015 and August 1, 2015 but was not passively enrolled, and
eligible individuals who are eligible for Passive Enrollment but are not due for
Medicaid renewal between June 1, 2015 and May 1, 2016.
• Also includes eligible individuals who are new to nursing homes
as of January 1, 2015.
27
Disenrollment
• FIDA participants can disenroll for any reason
• Contact NY Medicaid Choice at 1-855-600-3432, will be re-enrolled
in previous MLTC Plan
• Contact Medicare at 1-800-MEDICARE, to re-enroll in a Part D plan
• FIDA participants can only be involuntarily disenrolled for
specific reasons:
• Loss of eligibility for FIDA
• Absence from plan service area for more than 6 months
• Material Misrepresentation Regarding Third-Party Reimbursement
• Disruptive behavior (but only after serious effort to resolve, multiple notices to
member, and approval by CMS)
• Fraudulent enrollment application or abuse of FIDA card
• Participant knowingly fails to complete any necessary release form
MMP Enrollment Guidance §§ 40.2, 40.3 [pp. 41, 49]; Appendix 5: State-Specific FIDA Enrollment Guidance
for NY §§ 18-24 [pp. 9-12].
28
FIDA Considerations: Risks (compare plans)
•
Provider networks
•
Doctor, clinic, pharmacy, hospital, nursing home, home care agency
•
•
Plans have restricted networks, and those networks vary
Guildnet has a “point of service” network which promises any Medicare provider
will be paid the Medicare rate—unclear if providers will agree to procedures
•
Drug formularies
•
Even if pharmacy accepts FIDA, are the drugs needed covered?
•
Prior approval - Unlike Original Medicare, prior approval may be
required for certain procedures and services
•
Supplemental Coverage
•
Risk of losing retiree coverage for self and dependents
•
•
Requires investigation!
Medigap coverage: do not need under FIDA, but cannot get it back if
you drop it because of Medicaid rules
•
Consider keeping Medigap while test-driving FIDA!
29
FIDA Considerations: Benefits
• One insurance card
• Ombuds program “ICAN” (also available for MLTC) TEL 1-844-
614-8800 http://icannys.org
• No Medicare cost sharing (must still pay Medicaid spenddown)
• No deductibles or premiums, including Medicare Part B?? Unclear if
Part B is waived as initially promised. May only be if eligible for MSP.
• No copays for prescription drugs or doctors
• Inter-Disciplinary Team (IDT) makes care planning decisions
• Consumer, family, and doctors all participate Integrated/unified
appeals process (except for Part D)
• Internal appeal to the planState’s integrated hearing
officerMedicare Appeals CouncilFederal Court
• ONE notice – not separate Medicare and Medicaid notices.
• Aid continuing in ALL appeals, if requested within 10 days of the notice
30
FIDA Updated as of 4/18/2015
Announcement Letters
Sent to Region 1
(NYC, Nassau)
100,000
Total Enrollment
Total Number of
Opt-Outs
4,158 includes about
About
41,906
• 800 “voluntary”
• the rest “passive”
* 4,158 individuals were enrolled in FIDA on April 1. Between 4/1 –
4/18 – 1,101 has disenrolled for 5/1/2015.
31
NURSING HOME CARE “CARVED
IN” TO MLTC AND MAINSTREAM
MANAGED CARE - 2015
Permanent nursing home residents will be
required to enroll in an MLTC or Mainstream
MMC plan
32
Another “Medicaid Redesign Team” initiative
• Another step in NYS’ move to expand Managed Care for all
Medicaid services and populations.
• MRT 1458 – State policies posted at
http://www.health.ny.gov/health_care/medicaid/redesign/mrt_
1458.htm - scroll down to near last section:
February 1, 2015 (*) Population Transition – Nursing Home ("New" Duals and
Non-Duals) (FIDA Region Adults) (NYC, Nassau, Suffolk & Westchester)
• Link to DOH Webinar on transition (Jan 2015)
• DOH Powerpoint on NH transition (Jan 2015)
http://www.health.ny.gov/health_care/medicaid/redesign/docs/2015-0122_nh_transition_rev.pdf
• DOH Policy on Transition of NH Population to Managed Care (Feb 2015),
http://www.health.ny.gov/health_care/medicaid/redesign/docs/nursing_home_transition_final_
policy_paper.pdf
• FAQs Jan and Mar 2015 http://www.health.ny.gov/health_care/medicaid/redesign/2015march_transition_nursing_home_population_benefits_to_mmc_faq.htm
33
Nursing Homes and Managed Care
• Big Changes Starting STATEWIDE in 2015 for NEW permanent
residents in nursing homes -• Dual Eligibles -- will be required to stay enrolled in – or stay
in -- an MLTC plan when they need permanent nursing home
care; and
• People with Medicaid only – not Medicare- will be required
to enroll in or stay in a “mainstream” Medicaid managed care
plan if they need long-term nursing home care
• WHEN
• February 2015 – NYC
• April 1, 2015 - Long Island, Westchester
• July 1, 2015 – Rest of State
34
Until now – nursing home was “fee for service” –
not through managed care
1.
MLTC was mandatory only for duals who need home care
• Once an MLTC member needed NH placement, she would typically
“voluntarily disenroll,” even though NH is in MLTC benefit package
2.
• Would disenroll if didn’t like choice of nursing homes in MLTC plan’s
network, and receive nursing home FFS.
Mainstream Medicaid managed care (MMC) – for those with Medicaid
only and not Medicare –
• Before, members were disenrolled from the plans if they were in a nursing
home for more than 60 days. NH was paid “fee for service.”
• Now, all adult Medicaid recipients – when they
become permanent nursing home residents -- will be
required to enroll in or stay in a managed care plan
(MLTC for duals, MMC for Medicaid-onlies).
35
Current NH Residents Grandfathered in!
• NO ONE WILL BE FORCED TO MOVE - Permanent NH residents
are grandfathered in – No one is required to enroll in a plan if
they were in a nursing home and approved for institutional
Medicaid BEFORE:
• Feb. 1, 2015, and in NYC
• April 1, 2015 - Long Island, Westchester
• July 1 , 2015 (rest of state)
• But – after six months, “voluntary enrollment” begins for
these NH residents, when they MAY enroll in MLTC plans.
• Caution: Various Medicare Advantage plans – not FIDA – are
marketing to enroll residents. May happen in FIDA too.
• In NYC/L.I./Westchester, almost all companies with MLTC
plans will also have a FIDA plans and want to increase
market share.
36
When must new NH residents enroll in a
managed care plan?
• Depends on whether they were:
• Already in a nursing home before Feb. 1, 2015 (NYC) – if so, NOT required to
enroll in any plan. They are “grandfathered in.”
• Enter in a NH after Feb. 1, 2015 – then it depends on if they were:
• Already in an MLTC or mainstream MMC plan or
• Were not in an MLTC or mainstream plan at the time of NH placement
• Merely going into NH for short-term rehab does not require enrollment in
any plan. When they must enroll is still a bit unclear.
• We thought it was not til they apply for institutional Medicaid and it is approved
(with the 5-year lookback), but
• Now it seems that NH is required to file a “DOH-3559” with local DSS for change
of status to long-term care – within 48 hours of decision to make it “permanent
placement.” That could be within days of admission.
• Either way, resident would first receive notice from NY Medicaid Choice giving 60
days to select and enroll in a plan. If doesn’t enroll, would be assigned to a plan
that contracts with that NH.
37
Process for new nursing home admissions
• Consumers NOT already enrolled in MLTC/MMC
• Select and enter any nursing home of their choice
• When Medicare coverage ends, must apply for
Institutional Medicaid (Includes 5-year look-back and
transfer penalties)
• They will receive notice giving 60 days to pick a plan (pick
one that includes their nursing home in the network)
• If don’t pick a plan, will be auto-assigned to a plan that has
that NH in network (MLTC for duals, MMC for non-duals)
• Do not have to enroll until receive 60 day
notice from NY Medicaid Choice
• Possible advocacy: If expect to return home, then
appeal NYMC notice to select plan – because not a
permanent placement. (untried)
38
Process for new nursing home admissions (cont’d)
• Consumers already enrolled in mainstream Medicaid Managed Care
(MMC) plan (do not have Medicare)
• Must enter a NH in that plan’s NETWORK or Medicaid
will not pay for it
• MMC plan no longer will disenroll someone because
they need long term nursing home placement. Plan
must pay for NH.
• Plans should assess members who are NH residents
for possible discharge home and provide home care
services on discharge.
39
MLTC: Transition from hospital to NH
Where Already Enrolled in MLTC plan -• Rehab/ NH stays where Medicare pays primary – choice of NH is not
limited to MLTC plan’s network. MLTC plan must pay Medicare
coinsurance out-of-network too. DOH Q&A Aug. 16, 2012* - Question
42 on page 7. (also see Mar. 2015 Q&A #26.
• Once Medicare ends, if NH is not in the plan’s network, it is not clear
whether the MLTC plan must pay. Individual may change to MLTC plan
that has NH in network, but not effective until 1st of the next month. Old
MLTC plan should pay for reasonable time to transfer plans, but not clear.
• Upon discharge from NH, MLTC provides home care services
• Might have Medicare episode of CHHA arranged by MLTC,
supplemented with Medicaid MLTC hours
• No LOCK-IN – In both MLTC & MMC, may change in any
*http://www.health.ny.gov/health_care/medicaid/redesign/docs/mltc_faq2_final.pdf
month to a plan that has a preferred NH in its network
40
Minimum Network Size = # NHs required
# of NHs
Network minimum
Manhattan
16
5
Brooklyn
42
8
Queens
55
8
Bronx
43
8
Staten Island
10
5
Nassau
35
8
Suffolk
43
8
Westchester
38
8
Monroe, Erie
5
Oneida, Dutchess, Onondaga, Albany
4
Broome, Niagara, Orange, Rockland, Rensselaer,
Chautauqua, Schenectady, Ulster
3
All other counties
2 unless only 1 exists
Specialty NHs (AIDS/ vent/ behavior)
2 unless fewer exist
41
MEDICAID HOME CARE
APPLICATIONS
• New applications
• Tips for filing
• Special budgeting rules available for MLTC
42
New Applicants for Medicaid Home Care in NYC
Front Door Closed to apply through CASA/DSS unless in home
hospice or need only housekeeping (limited to 8 hours/week).
MLTC/HOME CARE
Medicaid application goes to:
HOUSEKEEPING ONLY (max 8 hrs/wk)
Medicaid application and M11q go to:
HRA HCSP Central Medicaid Unit
785 Atlantic Avenue, 7th Floor
Brooklyn, NY 11238
T: 929-221-0849
NYC HCSP Central Intake
109 East 16th Street, 5th Floor
New York, NY 10003
T: 212-824-0706 FAX 212-896-8814
NOTE: MLTC plans can’t give services
Medicaid-pending. Some will help
apply for Medicaid and w/pooled trust.
43
Tips for filing Medicaid applications
• Must complete Supplement A and provide current asset documentation
(+ last 3 months if want retro)
• Indicate on top of Application and Cover Letter that seeking MLTC (see
sample Cover Sheet)
• If client will have a spend-down – special steps:
• May be worth having MLTC plan file app, avoids “coding” problems
• Wait to enroll in pooled trust until AFTER Medicaid approved and
enrolled in MLTC. Faster.
• Submit any medical bills client has paid in last 3 months, and any
unpaid bills from before that.
• MARRIED APPLICANTS may only have a spend-down initially. Once
one spouse enrolls in MLTC, can request Spousal Impoverishment protections. More later. See form.
• Then go through Conflict Free Assessment
• Then have to enroll in a plan
44
Conflict-Free Eligibility & Enrollment Centers
(CFEEC) for new applicants
• 10-2014- State added a new step in enrollment for MLTC.
• After Medicaid is approved by local DSS, individual must do
“CFEEC” assessment by Maximus/NY Medicaid Choice. CFEEC
determines eligibility for MLTC.
• State aims to end “cherry picking” – plans recruiting people who don’t
even need any home care and turning away high-need people.
• Concern about delays. Supposed to take 7 days.
• CFEEC does not determine HOURS. Plan does.
• To schedule CFEEC call NY Medicaid Choice 1-855-222-8350.
• New CFEEC FAQ issued 3/27/2015 – posted on
http://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm
http://www.health.ny.gov/health_care/medicaid/redesign/2015-03-27_cfeec_faq.htm
45
Conflict-Free Assessment con’d.
• Roll-out schedule:
• As of Feb. 1, 2015 CFEEC mandatory in NYC, Nassau, Suffolk, & Westchester
• Mar – June 2015 – all other counties added. Timeline at
http://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm
• Nurse conducts assessment using same Uniform Assessment Tool
as MLTC plans. Conducted in-home, hospital or nursing home.
• TIP: MAKE SURE FAMILY OR SOCIAL WORKER ARE AT ASSESSMENT!
• TIP: Have MD letter/M11q with diagnoses, meds, functional impairments
at assessment
• No new assessment needed if transferring from plan to plan, or
from a previous Medicaid LTC service (including nursing home
care). Just new applicants.
• https://www.health.ny.gov/health_care/medicaid/redesign/mrt_90.htm
• http://nymedicaidchoice.com -On home page click on Do I Qualify for Long Term Care? Direct link
http://nymedicaidchoice.com/ask/conflict-free-evaluation-and-enrollment-center
46
Options for dealing with spend-down
• Start from the top of the list and rule out each option before
proceeding to the next.
REDUCE or ELIMINATE SPEND-DOWN
1.
a.
b.
c.
2.
3.
Nursing Home Transition Shelter Allowance
Spousal Impoverishment Budgeting
Enroll in a pooled income trust
(but wait to submit trust and other forms AFTER
Medicaid approved with spend-down)
Negotiate the spend-down with the plan
Pay the full spend-down to the plan
Upon MLTC
enrollment
47
1a) Nursing Home/ Adult Home Transition Shelter
Allowance
If Medicaid made a payment for a nursing home or adult
home stay, Medicaid will deduct a regionally-standardized
shelter cost from income upon discharge where the
individual:
• Has been in a NH for at least 30 days (not counting the day
of discharge);
• Is eligible for/enrolled in an MLTC plan upon discharge;
and
• Is not receiving spousal impoverishment budgeting
• Married individuals participating in PACE cannot get this
N.Y. Dep’t of Health, ADMINISTRATIVE DIRECTIVE: SPECIAL INCOME STANDARD FOR HOUSING
EXPENSES FOR INDIVIDUALS DISCHARGED FROM A NURSING FACILITY WHO ENROLL INTO THE MANAGED
LONG TERM CARE (MLTC) PROGRAM, 12 OHIP/ADM-5 at 2-4 (Oct. 1, 2012); GIS 14 MA/17
(Aug. 5, 2014).MEDICAID ALERT (FEB. 14, 2013)—FORM MAP 3057(E) IN NYC
48
2014 Special Income Standards for Housing Expenses
Region
Counties
Deduction
Central
Broome, Cayuga, Chenango, Cortland, Herkimer, Jefferson,
Lewis, Madison, Oneida, Onondaga, Oswego, St. Lawrence,
Tioga, Tompkins
Long Island
Nassau, Suffolk
NYC
Bronx, Kings, Manhattan, Queens, Richmond
$972
Northeastern
Albany, Clinton, Columbia, Delaware, Essex, Franklin, Fulton,
Greene, Hamilton, Montgomery, Otsego, Rensselaer, Saratoga,
Schenectady, Schoharie, Warren, Washington
$435
North
Metropolitan
Dutchess, Orange, Putnam, Rockland, Sullivan, Ulster,
Westchester
$786
Rochester
Chemung, Livingston, Monroe, Ontario, Schuyler, Seneca,
Steuben, Wayne, Yates
$372
Western
Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara,
Orleans, Wyoming
$315
$380
$1,066
N.Y. Dep’t of Health, GENERAL INFORMATION SYSTEM MESSAGE: EXPANSION OF THE SPECIAL INCOME STANDARD FOR HOUSING
EXPENSES TO INDIVIDUALS DISCHARGED FROM AN ADULT HOME AND THE 2014 LEVELS FOR THE SPECIAL INCOME STANDARD FOR
HOUSING EXPENSES, GIS 14 MA/17 (August 5, 2014).
49
2015 housing disregard has not been released
yet but… (think about renewals)
• “Within each region, the Housing and Urban Development (HUD)
Fair Market Rent (FMR) dollar amounts for a one bedroom
apartment were averaged. From this amount, 30 percent of the
Medicaid Income Level for a one person household was subtracted
(30 percent of $792 is $238). [NYC housing disregard for 2012 was
$1042]”-- N.Y. Dep’t of Health, ADMINISTRATIVE DIRECTIVE: SPECIAL INCOME STANDARD FOR HOUSING
EXPENSES FOR INDIVIDUALS DISCHARGED FROM A NURSING FACILITY WHO ENROLL INTO THE MANAGED LONG
TERM CARE (MLTC) PROGRAM, 12 OHIP/ADM-5 at 2-4 (October 1, 2012)
• GIS 14 MA/17 references the same formula to arrive at the 2014 numbers
• HUD FMR found at: http://www.huduser.org/portal/datasets/fmr.html
FY
HUD FMR
DAB Limit HH of 1
30%
Housing disregard
2012
$1,280
$792
$238
$1042
$1,243
$800
$240
•2013?
HUD FMR
for FY 2015
is $1249 for a one
bedroom$1003?
apartment
2014
$1,215
$809
$243
$972
2015?
$1,249
$825
$247
$1002?
50
Example budget with
NH transition shelter allowance
Gross monthly income
Health insurance premiums
Unearned income disregard
Shelter deduction (NYC—2015)
$2,213
(Medicare Part B)
(Medigap)
- 105
- 261
- 20
- 1002
Net countable income
$825
Income limit for single (2015)
- 825
Excess income
$0
51
Getting home from nursing home
• Catch 22: can’t get home and receive home care without
MLTC, but no MLTC plan will assess in nursing home! Plus –
MLTC enrollment only on 1st of month – must coordinate
discharge & starting services.
• After lengthy advocacy, DOH released guidance in May 2014
requiring MLTC plans to assess applicants in NH.*
• Plan must also visit community residence, but applicant need not be
present for that visit (arrange for family to give access)
• HRA Medicaid Alert of Feb. 14, 2013 “MLTC Submissions of
Nursing Home Enrollments” explains enrollment in NYC
http://wnylc.com/health/download/439/
* N.Y. Dep’t of Health, MLTC POLICY 14.04: MLTCP POTENTIAL ENROLLEE ASSESSMENTS (May
22, 2014),
http://www.health.ny.gov/health_care/medicaid/redesign/docs/mltc_policy_nursing_
home_assess_v2.pdf
52
Nursing home discharge - Strategy
YOU must coordinate 3 parties and carefully time discharge.
1. MLTC plan must assess client in NH and agree to enroll her
effective 1st of next month.
• Plan must fax NYC HCSP-3047b MLTC/NHED COVER SHEET
with expected enrollment date + signed enrollment
agreement.
• NH must fax NYC MAP-259f Discharge Notice
2. HRA Home Care Services Program Medicaid unit must
convert “code” from nursing home to community eligibility
effective 1st of next month. (929) 221-0849
3. NH & plan must arrange discharge on 1st with MLTC plan
starting services. If 1st of month on a weekend, or plan can’t
start services on the 1st , may be able to enroll on the 1st but
discharge a day or two later. Plan would pay for NH care for
those days.
53
1b) Spousal Impoverishment Budgeting
• Spousal impoverishment budgeting, previously only for nursing home and
waiver programs, is now available to married couples where one spouse is
in MLTC.
• If applicant has a community spouse, he/she may shelter up to $2,980/mo.
(2015) of joint income (and up to $74,820 of assets).
• It works almost the same as for nursing home, but with some minor
variations.
• See example of budget on next page.
Use Request for Assessment Form – at p. 9 of this update
http://www.health.ny.gov/health_care/medicaid/program/update/2014/mar14_mu.p
df . Send to HCSP Centralized Medicaid Eligibility Unit
785 Atlantic Avenue, Brooklyn, NY 11238
54
Example budget with spousal impoverishment
* Applicant Spouse - $2,130/mo. Income
* “Community Spouse” - $1,500/mo. income
Gross monthly income – Applicant
$2,130
Personal Needs Allowance (2015)
- 384
Community Spouse Monthly
Income Allowance (CSMIA)
Health insurance premiums
MMMNA ($2,980) - Otherwise
Available Income of spouse
($1,500) =
- 1,480
(Medicare Part B)
(Medigap)
- 105
- 161
Excess income
N.Y. Dep’t of Health, Medicaid Update Vol. 30, No. 3 at 5-9 (March 2014); N.Y. Dep’t of Health, GENERAL
INFORMATION SYSTEM MESSAGE: SPOUSAL IMPOVERISHMENT BUDGETING WITH POST-ELIGIBILITY RULES FOR INDIVIDUALS
PARTICIPATING IN A HOME AND COMMUNITY-BASED WAIVER PROGRAM, GIS 12 MA/013 (April 16, 2012); N.Y. Dep’t of
Health, MEDICAID REFERENCE GUIDE: INCOME at 278-282 (June 2010).
$0
55
Problem: Spousal Impoverishment only
available AFTER on Medicaid
• Spousal Impoverishment is a “post-eligibility” methodology.
• Married person must APPLY for Medicaid using regular
community Medicaid rules.
• This would require use of SPOUSAL REFUSAL if spouse’s income would
create a large spenddown, or if spouse’s assets disqualify the applicant
spouse from Medicaid.
• The applicant may have a high spend-down using regular community
Medicaid rules. In the example on the previous slide, even if the
“community spouse” did a spousal refusal, so that $1,500/month income
isn’t counted, the Applicant’s Spouse’s income of $2,130 would create a
high spenddown. But just for one month, because right after she enrolls
in an MLTC plan, she can request Spousal Impoverishment budgeting and
will have NO spenddown.
• A pooled trust wouldn’t be worth the trouble.
56
Hot issue – May a married MLTC enrollee use a
pooled trust?
• In 2013, a married MLTC enrollee could choose either spousal
impoverishment rules or use community budgeting– with a
pooled trust -- as a household of one
• This allowed enrollees to choose community budgeting with
pooled trust if better; i.e. if community spouse had her own
income over $2980, applicant couldn’t give her part of his own
income as a spousal allowance – has a spend-down.
• 8/5/14 - DOH issued a GIS making spousal impoverishment
rules mandatory, and eliminating the option of a pooled trust
for MLTC enrollees. Suffolk County rebudgeted all couples!
• 11/3/14 – DOH rescinded 8/5/14 GIS and issued new GIS 14
MA/025 – but stay tuned! Pending CMS clarification.
N.Y. Dep’t of Health, GENERAL INFORMATION SYSTEM MESSAGE: SPOUSAL IMPOVERISHMENT
BUDGETING WITH POST ELIGIBILITY RULES UNDER THE AFFORDABLE CARE ACT- GIS 14 MA/25 (NOV.
3, 2014).
57
Dealing with Spend-down – Enrollment Delays
• See handout on Spend-down Tips. Since we advise NOT to submit pooled
trust with application, because of delays, and you can’t get Spousal
Impoverishment protections initially, client will have a spend-down at first.
If plan refuses to assess and/or enroll client because code says Not Eligible:
• Give the plan a copy of the notice approving Medicaid.
• Give the plan the HRA HCSP FAQ dated Nov. 13, 2013 (copy in handout
and posted at http://www.wnylc.com/health/download/449/ )
• Tell the plan it must fax a MAP Medicaid Cover Sheet Form HCSP-3047a
(MLTC/PRU Cover Sheet a/k/a “CONVERSION FORM”)(updated
1/26/2015) to the HRA HCSP MLTC Provider Relations Unit, requesting
that the eligibility code be changed.
• TEL: (929) 221-2427
Fax: (718) 636-7848 - copy attached and
posted at http://www.wnylc.com/health/download/450/.
• DO NOT use “pay-in.” Causes problems.
• Gets complicated if you want to access CHHA pending MLTC
enrollment. You will need to get codes changed…
58
NAVIGATING MLTC
•
•
Service Authorizations, Concurrent Review
Grievances and Appeals
Model MLTC Contract – download at
http://is.gd/NY_MLTC_contract
59
Requesting Services:
Terminology
•
“Prior Authorization”
• Asking the plan for a new service, whether for a new
authorization period or in an existing authorization period,
OR
• Asking the plan to change a service in the plan of care for a
new authorization period
• Consumer or Provider can make the request
•
“Concurrent Review” – increase in home care hours
• Asking the plan for additional services (i.e., more of the same)
that are currently authorized in the plan of care; or
• Medicaid covered home health care services following an
inpatient admission.
Model Contract, Appendix K, at p. 135 of PDF
60
Service Authorizations: Timing
•
Concurrent review – plan decision due date:
Type
Maximum time
Expedited
3 business days from
receipt of request
Standard
14 days from receipt
of request
Medicaid covered
home health care
services following
an inpatient
admission
Minimum time
Within 1 business day of
receipt of necessary info
1 business day after
receipt of necessary info;
3 business days from
but if the day after the
receipt of request
request is on a weekend
or holiday, 72 hours after
receipt of necessary info
Model Contract, Appendix K, at p. 135 of PDF
61
Service Authorizations: Timing
•
Prior authorization – plan decision due date:
Type
Expedited
Standard
Maximum Time
Minimum Time
3 business days from receipt of request
14 days from receipt of
request
Within 3 business
days of receipt of
request for
services
• ALERT – Plans don’t meet these deadlines, or fail to process these
increases altogether – care manager may fail to pass the request
on to the appropriate personnel, or give no notice of appeal
rights. Must be assertive and file internal appeals
Model Contract, Appendix K, at p. 135 of PDF
62
Advocating for more Hours – with Plan or at
Fair Hearing
• All managed care plans must make services available to the same extent
they are available to recipients of fee-for- service Medicaid. 42 U.S.C. §
1396b(m)(1)(A)(i); 42 C.F.R. §§ 438.210(a)(2) and (a) (4)(i). The Model
Contract also states: “Managed care organizations may not define covered
services more restrictively than the Medicaid Program.”
• In other words, there has been NO CHANGE in the amount or type of
services available under MLTC versus under PCA/CHHA.
• If medically appropriate for 24-hour care (even split-shift) under the PCA
regulations, then that person should receive 24-hour care under MLTC.
• See GIS 12 MA/026 for live-in vs. split shift (only 2 pages long!)
http://www.health.ny.gov/health_care/medicaid/publications/docs/gis/12ma026.pdf
63
More on standards for authorizing amount of hours
Plans must follow Medicaid personal care rules
• Can’t use task-based-assessment when client has 24-hour needs
•
•
•
•
•
(“Mayer-III”) 18 NYCRR 505.14(b)(5)(v)(d);
New def’n of 24-hr care (in previous slide; GIS 12 MA/026)
Hours given must ensure safe performance of ADLs (GIS 03 MA/003)
Non-self-directing people are eligible if someone can direct care;
such person need not live with the consumer (92-ADM-49)
Cannot reduce services without justification. Mayer v Wing
Plans must reinstate services after hospitalized or in rehab (Granato
v. Bane, 74 F.3d 406 (2d Cir. 1996); GIS 96 MA-023)
• Need notice if terminating services
See http://wnylc.com/health/entry/114/ &
http://wnylc.com/health/entry/7/
63
64
Advocacy: Terminology
• Grievance
• Complain to plan about quality of care or treatment but not
about amount or type of service that was approved (i.e., how
the plan or its contractors are doing things) EXAMPLES:
• Chronic lateness or no-show of aide or nurse or care manager;
• Can’t reach care coordinator or other personnel by phone;
• Transportation delayed in taking to or from MD, day care
• Appeals
• Object to AMOUNT or TYPE of service approved
• Denial/termination of enrollment because allegedly “unsafe” at
home;
• Denial, reduction or termination of any service;
•Terminology is important here—no A/C for denials!
• Failure to process or respond to request
See http://www.wnylc.com/health/entry/184/
65
Plans must give written notice of initial plan of care
and any changes in plan of care
• Denials
• Authorizations/ Reauthorizations - Notice of Action
• At least 10 days before the intended change in services, the
plan must send a written notice to the member, containing:
• The action the plan intends to take,
• The reasons for the action, including clinical rationale,
• Description of appeal rights, including how to request appeal
and how to seek an expedited appeal, AND
• If a reduction/discontinuation, the right to aid continuing
• You still have the right to appeal a reduction or denial even If
plan doesn’t give written notice
http://www.wnylc.com/health/entry/184/.
66
NEW: Must Request Internal Appeal First
Before Fair Hearing
•
•
•
•
•
An appeal may be filed orally or in writing.
• Oral: plan must follow up with written confirmation of oral
appeal. Date of oral request is treated as date of appeal.
Plans must designate one or more qualified personnel who were
not involved in any previous level of review or decision-making to
review the appeal
If the appeal pertains to clinical matters, the personnel must
include licensed, certified or registered health care professionals.
Plan must provide a reasonable opportunity to present evidence,
and allegations of fact or law, in person as well as in writing.
Plan must provide the opportunity to examine the case file and
any other records.
42 CFR §§ 438.402, 438.406;
Model Contract, Appendix K, ¶¶ (1)(B) [p. 106 of PDF]
67
Expedited Appeals / Grievances
•
•
•
If you don’t have Aid Continuing, make sure to ask for
Expedited Appeal. The plan must decide an expedited appeal
within 3 days instead of 30 days. Plan must agree that a delay
would seriously jeopardize the enrollee’s life or health or ability
to attain, maintain or regain maximum function; or
The plan may deny a request for an expedited review – best
practice is to have doctor explain in writing jeopardy to health
or ability to function without services.
Note: Appeals of concurrent reviews are automatically
expedited (logical when you consider def’n of concurrent
review is a little more “immediate”; whereas prior auth. can be
for the next authorization period)
42 CFR § 438.410;
Model Contract, Appendix K, ¶¶ (1)(A) & (B)
[pp.103, 106 of PDF]
68
Aid Continuing Change in MLTC
• Plan must continue benefits unchanged whenever it proposes to
reduces or terminate services if :
• the appeal is timely requested (within 10 days of notice or before
effective date of the action)
• the appeal involves the termination, suspension, or reduction of a
previously authorized course of treatment;
• the services were ordered by an authorized provider;
• the enrollee has expressly requested Aid Continuing
• Before April 1, 2014, Aid Continuing was required only if the original
authorization period for the service has not expired. The State 201415 budget eliminated that requirement!!! Plan must continue
services even if that period expired.
42 CFR § 438.420; NY Soc. Serv. L. § 365-a(8); N.Y. Dep’t of Health, MLTC POLICY 14.05: AIDCONTINUING TO BE PROVIDED WITHOUT REGARD TO THE EXPIRATION OF PRIOR SERVICE AUTHORIZATION (August 6,
2014) at
https://www.health.ny.gov/health_care/medicaid/redesign/docs/mltc_policy_authorization.pdf
69
Advocacy Tip:
No Notice or Notice is Unclear
• If MLTC – request an internal appeal with the plan with AID CONTINUING.
• If MLTC plan refuses to restore Aid Continuing, call NYS Department of Health
Complaint Hotline
(866) 712-7197 and cc [email protected]
• If Mainstream managed care – request a fair hearing with the State
immediately and request aid continuing.
http://otda.ny.gov/oah/FHReq.asp
• Plans rarely give proper notice! Client
has appeal rights even if no notice!
70
Taylor v. Zucker
• NYLAG filed a class action filed July 15, 2014 on behalf of
Medicaid recipients in New York State who receive home
care services through Managed Care Organizations (“MCOs”),
against DOH and OTDA, challenging their failure to send
timely and adequate notices of denial, reductions, and
terminations, and to provide an opportunity for a Fair
Hearing and aid-continuing, in violation of the Due Process
Clause of the U.S. Constitution and the Medicaid Act and its
implementing regulations.
• If you have a client who you believe may be a member of the
Taylor class please contact [email protected].
Taylor v. Zucker, No. 14-CV-5317 (SDNY July 15, 2014)
71
Contact numbers & Other Info
•
•
•
•
•
New York Medicaid Choice (Enrollment Broker)
• To request a Conflict-Free Assessment (after Medicaid approval) 1-855-222-8350
• For information about MLTC
1-888-401-6582
• FIDA – for information or to OPT OUT
1-855-600-3432
• Maximus Project Directors
1-917-228-5607, -5610, -5627
• Website http://nymedicaidchoice.com/
• http://www.nymedicaidchoice.com/program-materials - Scroll down to Long
Term Care plans –
• http://tinyurl.com/MLTCGuide - Official guide to MLTC
NYS Dept. of Health MLTC/FIDA Complaint Hotline 1-866-712-7197
[email protected]
NYS DOH Mainstream managed care complaint hotline 1-800-206-8125
[email protected]
Consumer FIDA Ombudsprogram – ICAN – 1-844-614-8800 http://icannys.org
Related online articles on http://nyhealthaccess.org:
• All About MLTC - http://www.wnylc.com/health/entry/114/
• Tools for Choosing a MLTC Plan http://wnylc.com/health/entry/169/
• Appeals & Grievances - http://www.wnylc.com/health/entry/184/
• MLTC News updates: http://www.wnylc.com/health/news/41/
• FIDA news updates http://www.wnylc.com/health/news/33/
71